Intake & Consent: Adult

We are delighted that you have chosen to embark on this journey with us. Completing this intake form is the first step towards creating a supportive and personalized experience tailored to your needs. Your comfort and well-being are our top priorities. The information you provide will help us understand your unique situation and how best to support you. Rest assured, everything shared here is kept confidential, and we encourage you to take your time as you fill out the form. If you have any questions or need assistance at any point, please don’t hesitate to reach out. We are here to support you every step of the way.

Please note the following:

  • There are two places where a signature is required, which you can do easily from any mobile device, tablet or computer.
  • Fields do not save and the form must be completed in one sitting. It will take about 10 mins to complete.
  • Click Submit when done.

If you have any issues or questions about this form please contact our office.


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Personal Information

Full Name
Preferred Contact Method
Please select one
Address

History and Personal Information

To assist your Therapist in preparing for your first appointment. Please complete all fields, put N/A if not applicable.
Request for:
Please select one
Indicate name, dose and purpose
Marital Status
Provide Name and Phone Number
What is your current occupation and educational history?
Are you involved in any custody, access dispute, disagreement or any legal difficulties
How would you rate your physical health?
Do you drink alcohol?
Do you use recreational substances?
Do you have concerns about your substance use?

CONSENT 

Nature of Counselling:

The Therapists at Your Counselling Ltd approach counselling from an integrative perspective using modalities such as Client-Centered, Cognitive- Behavioural, Narrative Therapy, Dialectal Behavioral, and Solution Focused techniques.

We encourage you to ask questions regarding your Therapist's education, training and credentials during your initial session. You can also review their profiles and education by going to: https://www.yourcounselling.ca/get-to-know-us/


Counselling Services:

Counselling is a complex and personalized process, shaped by the unique personalities of both the counsellor and the client, as well as the specific issues addressed during sessions. Effective counselling requires active participation from the client, with progress often extending beyond the office setting. While counselling can bring numerous benefits, such as improved relationships, new coping strategies, skill development, reduced distress, changes in unwanted behaviours, and enhanced self-esteem, it can also evoke difficult emotions like sadness, guilt, anger, frustration, loneliness, or helplessness. The counselling process involves personal exploration and reflection on life perspectives and decisions. Initial sessions typically focus on assessing the client's needs, after which a treatment plan may be developed if both parties choose to continue therapy. Clients are encouraged to evaluate their comfort level with the therapist, as therapy demands a significant commitment of time, money, and energy. Any questions regarding the therapist’s procedures can be addressed at any point during the process.

Confidentiality:

Confidentiality is a fundamental right of all clients seeking counselling. Any information shared during sessions is kept strictly confidential and will not be disclosed without the client’s written consent, except in specific cases. These include: (a) Duty to Warn, where the counsellor must notify appropriate parties if a client poses a danger to themselves or others, or if there is suspected or confirmed abuse involving a child, elder, or vulnerable person. (b) Court Subpoenas, where legal cases may require the disclosure of the counsellor’s notes or records. (c) Consultation, where information may be discussed confidentially with other counselling professionals to ensure the client receives the best possible care, without revealing the client’s identity.

Clients’ Rights:

Clients have the right to ask questions about any aspect of their therapy. Therapists are open to discussing their methods and are willing to explore alternatives that may better suit the client’s needs. Clients are encouraged to request adjustments or refuse certain counselling techniques if they do not feel comfortable. Additionally, clients may inquire about the therapist’s qualifications and can request a referral if they feel the therapist is not the right fit. Clients are free to discontinue therapy at any time, though a termination session is recommended for closure.

Record Keeping:

Professional standards require therapists to maintain treatment records. These records are brief, noting attendance, interventions, and discussion topics. Clients have the right to review their records in the presence of the therapist, and they may request corrections for any perceived errors. Records are securely stored for seven years following the termination session and are maintained by the therapist, who ensures proper document control and confidentiality.

Contacting your Therapist:

Therapists may not always be immediately available by phone. Voicemail is typically monitored, with responses provided within 36 hours. Emails are also generally answered within the same timeframe. In cases of extended absence, the therapist will provide an alternate contact. The administrative team is available Monday through Friday for scheduling assistance.

Emergencies:

In case of an emergency between sessions, clients are advised to contact the Distress Centre Calgary (403-266-4357), visit the nearest Emergency Room,  or Urgent Care Center, or call 911.

Clinic Structure:

Therapists operating under the name "Your Counselling Ltd" are independent practitioners and not business partners. While they may collaborate on clinical or business matters when necessary, each practitioner is autonomous. All client concerns are addressed directly between the client and their respective therapist. If needed, clients may request the contact information of the therapist’s governing body based on their clinical registration.

Clear Signature
Upon signing, you are indicating that you have read and understood this consent form. You agree to accept the counselling services as detailed above.

Fee Schedule 

Effective July 18, 2023 

Standard Rates:

Individual Counselling: $160.00 to $180.00 per 50 min session.  (Rates for each Therapist are posted here.

Couple/Family Counselling: $200.00 per 50 min session; or $300.00 for a 90 min session

Accelerated Resolution Therapy (ART) or EMDR:  90 min. session is $ 225.00 or 75 min session $190.00

Document/Letter Writing: $160.00 per hour.

Fees are billed in 15 min increments based on session type should any variation need to occur. In these instances, for extended or shortened Sessions, fees will be discussed with your therapist. Fees are paid following each session. Debit, Credit, Cash, and E-Transfer are all accepted forms of payment. Detailed receipts are provided following payment.

While we offer direct billing to various insurance companies we cannot speak to the level/type of coverage you have as we are not able to access this information.

Any balance not covered by direct billing is payable at the end of your session.   

CANCELLATION AND MISSED APPOINTMENT POLICY

We consider any appointment that you have made important. Your appointment is for your exclusive use and when it is cancelled with short notice, or missed altogether, it is too late or impossible to offer this time to someone else and the appointment time goes unfilled.

The following outlines how missed and late cancelled appointments are handled:

  • A full 24-hour notice period is required for cancelling appointments.
  • Confirmation from either our booking system or our admin team is required for confirm a session has been successfully cancelled.
  • If you cancel with less than 24 hours before your appointment time, you will be billed for 100% of the cost of your appointment.
  • Clients who fail to show up for a scheduled appointment (“no show”) are billed/invoiced for the full cost of their scheduled session.
  • Our booking system will send out reminder emails. These reminders are a courtesy only; clients are responsible to keep or cancel their appointment regardless of whether they receive a reminder or not.
  • If you are uncertain when your next appointment is, please call our office.
  • There is a range of valid reasons for cancelling an appointment. To be consistent with all clients, cancellation fees will only be waived in the event of a documented medical emergency requiring urgent professional treatment, a death in the family or unsafe weather for travelling (i.e. severe snowstorm).
  • If you have booked a series of counselling appointments and have cancelled your most recent appointment with less than 24 hours’ notice or have missed that appointment, you have 24 hours to pay the associated fees to retain your remaining pre-booked sessions.
  • Missed appointments and late cancellations are payable via debit, credit, cash or e-transfer prior to your next session.
  • All no-show fees or cancellations fees collected have receipts marked “cancellation fee” or “missed appointment” and cannot be marked as a “counselling session”.
  • We are unable to direct bill your insurance for any late cancellation or no show appointments.
  • Weekend Appointments must be cancelled by the Friday before the appointment occurs.
  • Clients with overdue invoices and funds owned are not able to book sessions.

Our reception team is open Monday – Friday from 9:00 am to 4:00 pm (MST/MDT)  and can support you in your scheduling needs.

Clear Signature
By signing above, you are indicating that you have read and understood the fee agreement