Intake Forms (Counselling)

There are 2 forms to fill out on this page - please read and fill out both forms before your appointment!

FORM 1 - Agreement

Statement of Understanding / Confidentiality Agreement

Counselling is a partnership between counsellor and therapist. The process will involve clarifying the problem (s) that brought you to counselling or coaching, developing a plan to address them, and working with the support of your counsellor/coach toward problem resolution. In some situations, a referral to another resource may be indicated, if so, your counsellor will assist you with this process. With your permission, your counsellor may contact a community resource to ensure a smooth transition. The client may stop treatment with the therapist at any time, if this occurs the client will be responsible for the services rendered.

Confidentiality and Client Rights

  1. All counselling/coaching services are confidential.
    No information will be provided to anyone without your signed, informed consent. There are some important exclusions to the above:

    ●  Child welfare concerns

    ●  Imminent self-harm, danger to others, or medical emergency

    ●  Subpoena or court order

  2. Anonymous information may be reviewed with a CPCA approved Clinical Supervisor for the purpose of continued education and excellence of the services provided.

  3. A record is kept of services provided to you. All records are confidential and access to them will be granted to you upon request.

  4. Client confidentiality is of utmost importance, however online communication is not 100% secure. There are risks involved and it is important that you are aware we cannot guarantee your protection.

  5. Invoicing is done through online Wave Accounting System, It is understood that this accounting system holds access to the information you provide specifically for billing purposes.

Consent to Counselling

  • Payment for counselling/coaching is required at the end of each session.

  • The agreed upon amount + GST will be paid in full at the end of each session.

  • Twenty Four hour notice is required to cancel an appointment. Failure to provide this will result in being billed for 50% of the session fee.

I have read the above, understand its content, and consent to the counselling process.

FORM 2 - Intake Form

Please note: information provided on this form is protected as confidential information.