Intake Form Please provide the following information and answer the questions below. *For couples or families, you may fill out only one form if preferred. Date: Name: Last First DOB: Age: Gender:MaleFemaleOther Last First DOB: Age: Gender:MaleFemaleOther Last First DOB: Age: Gender:MaleFemaleOther Name of parent/guardian (if under 18 years): Last First DOB: Age: Marital Status: Never MarriedCommon LawMarriedSeparatedDivorcedWidowed Please list any children, age, and relationship Guardianship Agreement (no guardianship,sole, or shared) Name/Contact info of guardian holders I understand it is my responsibility to confirm with the other parent that I am bringing our child for counselling. Address: City: PC: Contact Information: Home Phone: May we leave a message?YesNo Cell/Other Phone: May we leave a message?YesNo E-mail: May we email you?YesNo *Please note: Email correspondence is not considered to be a confidential medium of communication. Hours of Availability: Monday 9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm Tuesday 9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm Wednesday 9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm Thursday 9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm Friday 9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm Other: Financial Information: Counselling Rate: (Rate Based on combined household income: Insurance Coverage: yesno Sponsored By: Counsellor RCC# Do you have a preference for :Female counsellorMale counsellorEither In-person counsellingVirtual counsellingEither How did you hear about Cares? Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? No Yes, previous therapist/practitioner Type of Treatment Are you currently taking any prescription? No Yes (Please list) Have you ever been prescribed psychiatric medication? No Yes (Please list and provide dates) General Health and Mental Health Information 1. How would you rate your current physical health? PoorUnsatisfactorySatisfactoryGoodVery good Please list any specific health problems you are currently experiencing 2. How would you rate your current sleeping habits? PoorUnsatisfactorySatisfactoryGoodVery good Please list any specific health problems you are currently experiencing 3. How many times per week do you generally exercise? What types of exercise to you participate in? 4. Please list any difficulties you experience with your appetite or eating patterns 5. Do you currently experience overwhelming sadness, grief or depression? NeverRarelySometimesOftenAlways If yes, when did you begin experiencing this? 6. Do you currently experience anxiety, panic attacks or have any phobias? NeverRarelySometimesOftenAlways If yes, when did you begin experiencing this? 7. Do you currently experience any chronic pain? NeverRarelySometimesOftenAlways If yes, please describe? 8. Have you experienced a traumatic brain injury? NoYes If yes, please describe? 9. How often do you consume alcohol? DailyWeeklyMonthlyInfrequentlyNever a. On average, how much alcohol do you consume when you drink? 1-5 drinks5-10 drinksmore than 10 drinks 10. How often do you engage recreational drug use? DailyWeeklyMonthlyInfrequentlyNever 11. Have you experienced or are you currently experiencing events that you consider to be mentally, emotionally, and / or physically traumatic? NoYes If yes, please describe? 12. Are you currently in a relationship (including marriage and common law)? NoYes If yes, for how long? On a scale of 1-10 with 1 being the lowest, how would you rate your relationship? 13. Please list any significant life changes or stressful events that you have experienced recently Family Mental Health History In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.). Please Pick List Family Member Alcohol/Substance Abuse NoYes Anxiety NoYes Depression NoYes Domestic Violence NoYes Eating Disorders NoYes Obsessive Compulsive Behavior NoYes Schizophrenia NoYes Suicide Attempts NoYes Other conditions: Additional Infomation 1. Are you currently employed? NoYes If yes, what is your current employment situation? Do you enjoy your work? Is there anything stressful about your current work? 2. Do you consider yourself to be spiritual or religious? NoYes If yes, describe your faith or belief 3. What would you like to accomplish out of your time in therapy? **Please remind clients that Cares is a scent-free environment** Informed Consent and Limits of Confidentiality Counselling Counselling provides a space and opportunity for you to explore behaviours, relationships, feelings or thoughts. In working towards positive change, you may experience a wide range of emotions and changes in your relationships that can be both rewarding and stressful. Counselling can also bring deeper personal insight and awareness, better ways of understanding and coping with problems, and help you improve your relationships. You should know, however, that counselling sometimes requires your willingness to examine difficult topics or times in your life, to experience stronger than usual emotions, and to try out new and different behaviours. There is an expectation that in between sessions you will work to apply the new skills, complete homework and access other services as needed. Collection, use and disclosure of personal information Personal information gathered in the course of counselling will be used in accordance with the purposes outlined in the paragraph above and will not be disclosed except as follows: Confidentiality and its exceptions Confidentiality is a key to the effectiveness of the counselling process, so the personal information you share in counselling will be kept confidential. Confidentiality continues after the end of the counselling relationship. There are, however, some exceptions to the counsellor’s duty of confidentiality, in particular: (A) if a child is or may be at risk of abuse or neglect, or in need of protection; (B) if a counsellor believes that you or another person is at clear risk of imminent harm; (C) for the purpose of complying with a legal order such as a subpoena, or the disclosure is otherwise required or authorized by law. With your consent, the counsellor may also disclose information for the purpose of professional consultation with a staff supervisor or with a staff colleague. If you have any questions or concerns about how B.C’s Personal Information Protection Act or the counsellor’s personal information policies and procedures apply, please ask. Sponsorship In cases where a client is sponsored by various organizations, it may be required to have letters or conversations shared with the sponsoring agency regarding client progress. Please be sure to contact your sponsoring organization to clarify their requirements. Reviews, Referrals, and Ending In counselling, it is your right at any time to: (A) review your progress and any of the topics in this form (B) be provided with a referral to another counsellor or health professional (C) withdraw consent for the collection, use, or disclosure of your personal information, except where precluded by law (D) end the counselling relationship by so advising the counsellor (E) access or obtain a copy of the information in your counselling records, subject to legal requirements. Your right of access to or to obtain a copy of your personal information continues after the end of the counselling relationship. Concerns If you have any concerns about any aspect of your counselling, you are requested to first address it with your counsellor. If this is impossible or unsafe, or if your concern is not resolved through discussion, you may contact the Executive Director of Cares at 604-853-8916. If your concerns are not satisfied you may also contact the Registrar of the B.C. Association of Clinical Counsellors at 1-800-909-6303. Signature My signature below confirms that I have read the above, had an opportunity to discuss it with the counsellor, and had my questions answered to my satisfaction. Name of Client: Name of Client: Financial Policy At Cares, our mandate is to make counselling as affordable and accessible to our community as possible. Thus, while each 50 min. session costs Cares $135.00, we subsidize your rate based on your combined annual household income. Cares is able to subsidize your services because of the following initiatives: 1. The “Friends of Cares,” in which individuals, organizations, or companies provide monthly and/or annual tax-deductible donations to support the work of Cares. 2. Through various churches, insurance benefit plans, or other agencies that sponsor clients and are invoiced for the full cost of the counselling session. 3. Through clients and former clients who decide to support the work of Cares. If you are interested in partnering with us in one of these initiatives, please contact our office or visit our website at www.cares.ca. Outstanding Accounts It is expected that clients either pay weekly before each session or pre-pay for a number of sessions at one time. Missed payments will lead to the suspension of counselling services until payment in full has been made. Any arrangements can be made with the Office Administrator. Insurance It is your responsibility to inform us whether you have extended benefits that cover Registered Clinical Counsellors. Cancellation Policy 48 hours notice is required for all cancellations. Late cancellations or “no-shows” will have the per-session fee added to their account. Clients with two “no-shows” risk having their counselling suspended or terminated. Your signature below indicates that you have read and understood the information contained in this financial policy. If there is any portion of this policy that requires further explanation please be sure to make this clear to your counsellor before signing the document. I have read and understand the above information and agree to abide by the information herein. Name of Client: Name of Client:
