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Intake Form

Date of Birth
Month
Day
Year
Is it ok to leave a message at this number
Yes
No
Is it ok to email you?
Yes
No

Emergency Contact

Confidentiality is maintained for clients as far as possible but when a person or persons are at risk, confidentiality must be waived and the appropriate authorities or family members notified. Such situations include the following:

1.     The client is at risk of serious self harm or of considering suicide,

2.     Of harming another person or committing homicide,

3.     Abuse of children is a mandatory reporting offence which I am required to report by

law.

Note: Please be aware that on occasion, notes may be subpoenaed due to a court order.

              

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

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.

Please sign using your keypad

Date
Month
Day
Year

Cancellation Policy

We understand that at times you may find it necessary to cancel your appointment. And we would appreciate as much notice as you are able to give.


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