Rhodes Counselling Centre Intake form

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Do you consent to receiving voicemails at this phone number?*

Date of Birth*

Date

Are you 16 years of age or older?*

Are you a Canadian Citizen or Permanent Resident?*

Preferred Name

Pronouns

If you were referred, please provide the name of the student counsellor you were referred to:

First NationsMétisInuit

1. In the event that you are not a suitable candidate for one of our student counsellors, would you like the intake team to reach out with referrals to work with one of our alumni counesllors? Our alumni counsellors are established in their practice and can offer sessions starting as low as $50 per session. *

2. Have you ever received a formal mental health diagnosis by a licensed medical practitioner?*

If yes, Please list the diagnosis/diagnoses, When you were diagnosed and current medical treatment:*

3. Are you currently taking any prescribed medication for a mental health condition:*

If yes, please list the medication you are taking for your condition:*

Intent of harming yourself or othersSevere depression or mood swings that interfere with daily lifeHallucinations, delusions, or other symptoms affecting realityPersistent flashbacks or intrusive memories that impact your day to day activitiesFrequent or severe panic attacksProblematic substance use affecting your daily lifeEating difficulties or disorders affecting your health or daily functioningFeeling disconnected from your body, thoughts, or surroundingsCurrently involved in legal proceedings (e.g., court cases, custody disputes, or legal investigations)

7. What are your primary reasons for seeking counselling at this time*

Our counselling sessions are offered at no cost and are in high demand. In order to ensure fair access to services for all clients, we kindly ask that you provide at least 24 hours’ notice if you need to cancel or reschedule an appointment. If you do not attend a scheduled appointment without notice ("no-show"), or if you cancel with less than 24 hours' notice, you may be placed back on the waitlist for future services. Exceptions may be made in cases of emergency or extenuating circumstances, at the discretion of the counselling team.

The Counselling Centre is a student training clinic. All counselling sessions are conducted by student counsellors. These students are under the supervision of qualified, experienced professionals who provide ongoing guidance and oversight to ensure ethical and effective practice.

By agreeing to participate in counselling services, you are committing to a minimum of six sessions. This consistency supports both the therapeutic process and the student's learning outcomes.

As part of the educational component of our services, completion of a feedback form is mandatory. Your feedback is an essential part of the student’s learning and helps us maintain the quality of services provided.

In some cases, student counsellors may be required to record video sessions as part of their educational requirements. These recordings are strictly for academic review and supervision purposes only, and they are stored securely in accordance with privacy and confidentiality guidelines. You will be informed in advance if a session is to be recorded.

YesNo

Rhodes Counselling Centre Intake form

Informed Consent and Participation Agreement