Kira and Edward intake

Client Intake Form

All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose. This form was created using JotForm, all JotForm forms are secure (SSL) by default, this form is encrypted (meaning only Kira or Edward can read it) all data is stored on a secure German server - no data is stored in the US.

Full Name*

First NameMiddle NameLast Name

Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number*

This is my:*

If you know your dominant Enneagram type, please enter here

Don't know your enneatype? Visit www.openingworks.com Booking/Rates page to find link to free online tests. Please email us your results.

E-mail*

Occupation

Emergency Contact*

Phone Number*

Relationship to you*

How did you hear about our services?

Thank you.

With whom would you like an appointment?

Kira MacDuffee, Edward Colley, or Either

What brings you to seek therapy and what do you hope to gain?*

Medications

Past Year Checklist

Only respond to this area that applies to you. Please rate the level of distress these issues have caused you in the past year

Sleeping too much

	1	2	3	4	5

1 is none, 5 is extreme

Sleeping too little

	1	2	3	4	5

1 is none, 5 is extreme

Eating too much

	1	2	3	4	5

1 is none, 5 is extreme

Eating too little

	1	2	3	4	5

1 is none, 5 is extreme

Mood swings

	1	2	3	4	5

1 is none, 5 is extreme

Angry outbusts

	1	2	3	4	5

1 is none, 5 is extreme

Depression

	1	2	3	4	5

1 is none, 5 is extreme

Repetitive behaviors

	1	2	3	4	5

1 is none, 5 is extreme

Anxiety/Fear

	1	2	3	4	5

1 is none, 5 is extreme

Lack of energy

	1	2	3	4	5

1 is none, 5 is extreme

Loneliness

	1	2	3	4	5

1 is none, 5 is extreme

Caring for Others

	1	2	3	4	5

1 is none, 5 is extreme

Death/Major Loss

	1	2	3	4	5

1 is none, 5 is extreme

Past Trauma

	1	2	3	4	5

1 is none, 5 is extreme

Sexual Problems

	1	2	3	4	5

1 is none, 5 is extreme

Relationship Problems

	1	2	3	4	5

1 is none, 5 is extreme

Hear/See Things others cannot

	1	2	3	4	5

1 is none, 5 is extreme

Suicidal Thoughts/Actions

	1	2	3	4	5

1 is none, 5 is extreme

Physical/Emotional/Sexual Abuse

	1	2	3	4	5

1 is none, 5 is extreme

Drug/Alcohol (self or Other)

	1	2	3	4	5

1 is none, 5 is extreme

Concerns Regarding Family

	1	2	3	4	5

1 is none, 5 is extreme

Education/Work Concerns

	1	2	3	4	5

1 is none, 5 is extreme

Financial Concerns

	1	2	3	4	5

1 is none, 5 is extreme

Medical and Mental Health Treatment Information

Please describe your physical and mental health including significant hospitalization, illnesses, and/or medications

Are you currently receiving other mental health services or medical treatments?

Exercise

How often do you exercise

Preferred form of Exercise

Substance Use

	Never	Weekly	Daily
Alcohol
Tobacco
Marijuana
Other

If you choose other please give details

Do you participate in any spiritual ceremonies that use plant based medicine

YesNo

If yes please give details

Legal History

Are you involved in the Legal system or have you had significant legal issues in the past?

Are you currently involved, or expect to be involved, in an ICBC accident claim?

If Yes - briefly explain

Family History

Please give me a brief family history. Describe family of origin and your current family dynamics.

Relationship with Others

Please describe the important people in your life and the quality of the relationship.

Have you now or ever experienced violence, abuse, or threatening behaviour in a relationship

Trauma History

Please list any past traumatic experiences you have had (including but not limited to childhood abuse, military combat, assault, natural disasters, life threatening illness).

Strengths and Resources

What helps you make it through difficult times?

Who can you count on for support in times of need?

What gives you personal enjoyment?

What communities are you part of?

Do you have religious practices or spiritual beliefs that are important to you?

If there anything else you think we should know?

Please read about our rates, cancellation and confidentiality agreement:

We believe it is important for individuals to fully engage in their therapeutic work and the financial process required to see us.

If you are negotiating a reduced rate we encourage you to challenge yourself to pay an amount that is not completely comfortable.
We do not wish to contribute to 'financial karma', which means we prefer not to support you to hold onto old beliefs about yourself and money/lack of abundance, nor do we wish to dishonour the value of our own services and presence.

If you are unable to pay the hourly rate, we occasionally have openings available on a sliding scale.

Generally our sliding scale for individuals is $80-115 per hour.
These rates are negotiated on an individual basis according to financial need.
Note: When the demand for reduced rates is high you can expect a waiting period prior to our scheduling an appointment. If requested we will offer other referral options.

We ask individuals to pay our full rate of $115 per hour, and couples $165 per 1.5 hour (GST incl), if they are:

Employed full-time (at more than minimum wage jobs) Are fully supported by family or friends, or have third-party coverage.
We ask students to pay our student rate of $90 (GST incl). We ask individuals on disability or on pensions to pay our rate of $80 (GST incl).

Cortes Island Residents: $80 individual & $130 couples.

Please feel free to discuss your personal financial needs with us. We will certainly negotiate our rates, when space available, when individuals are truly interested in doing their personal work.

Payment can be made:

in-person at your appointment by: cash, cheque (note: client is responsible for all NSF fees for dishonoured cheque), or by credit card.
prior to your appointment by: online bank email money transfer; or via PayPal we appreciate your diligence in either bringing your payment with you or making your online payment in advance.

Cancellations: We request a minimum of 24 hours notice of cancellations or appointment time changes.

Late Cancellations: (notice given less than 24 hours before appointment start time) No Shows (no notice given for missing an appointment) Note: While it is our hope that the online calendar will send its 48 hour email notification to you, this does not happen 100% of the time. Please mark your appointment day and time on your personal calendar when booking. We will no longer be responsible for online calendar reminder email technical errors.

Late Cancellation fee: $115, unless there is time to fill the appointment slot, in which case the fee is $60.

No Show fee: $115. Since a 'no show' implies the person is already 15+ minutes late for their scheduled appointment, without any notice given, we will not be able to fill this slot with someone waiting to come in.

The cancellation/no show fees must be paid prior to your next appointment or services may be refused.

Multiple non-notifications ('no shows') may result in termination of services.

Emergency circumstances are understood. Please notify us as soon as possible.

We thank you for understanding.

Extended health plan coverage: Check your extended health benefits plan. You may be able to receive coverage for both our services through our RCC (Registered Clinical Counsellor) or Naturotherapist (Academy of Naturopaths & Naturotherapists of Canada) receipts.

Signature*

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