Intake Form

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

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

Emergency contact

Name

Their Phone Number

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

Relationship to you

Please tell us about BEHAVIOURS you care concerned with, to help guide an appropriate service for you:

Please describe any PHYSICAL symptoms you are concerned about:

Are you feeling suicidal now or have been in the last week?

Have you attempted to end your life in the past or recently?

Please Describe the following FEELINGS you are experiencing that are of concern:

Please list any medication you are prescribed to take and whether your script is up to date.

What do you hope to gain from your counselling sessions?

Confidentiality Agreement

This agreement outlines the conditions under which confidentiality is maintained between you, the client and your Counsellor.

Your counsellor commits to maintaining the confidentiality of all client information as far as possible.

Exceptions:

Confidentiality must be waived and the appropriate authorities or emergency contacts must be notified in the following circumstances:

If the client is at risk of serious self-harm or considering suicide
If there is a risk of the client harming another person or committing homicide
If there is knowledge of child abuse, which is a mandatory reporting offence and will be reported by law
If notes are subpoenaed by a court order
If there is a credible risk of harm within the workplace , such as threats or actions that could endanger the safety of employees or the environment.

Client Notification:

In instance where confidentiality cannot be maintained, the counsellor will take all possible steps to first inform/discuss their intention with the client.

Acknowledgement and Agreement:

I have read the above and understand the counsellor's social and ethical responsibility to make such decisions where necessary. I understand and agree to these conditions concerning confidentiality and have read and agree to the conditions of the cancellation policy.

Cancellation Policy

(a) Cancellations less than 48 hours before the time of your appointment incur a 50% cancellation fee.

(b) Failure to attend an appointment without providing prior notice incurs a 100% cancellation fee.

(c) If a medical certificate can be provided within 48 hours after the missed appointment, which demonstrates your inability to attend due to ill health, we may, in our sole discretion, agree to waive all or part of your cancellation fee.

(d) If your counsellor cancels the appointment due to unforeseen circumstances you will not be charged for the appointment.

(e) Respect must be shown to the Counsellor at all times. The safety of staff and client's is of the utmost importance. The service may be cancelled if the counsellor has been subjected to behaviours that are unsafe or disrespectful.

(f) If you have missed more than 2 scheduled appointments without notice, we may review whether to continue to provide a service.

Signature