Intake Form for New Clients Name * First Name Last Name Phone Number Email * Date of Birth * Month/Day/Year Preferred Pro-Nouns * Please Choose your Preferred Pro-Nouns. If other, please let me know if the "other" information below She/Her He/Him They/Them Other Address Address 1 Address 2 City State/Province Zip/Postal Code Country Occupation What, if anything, is important for me to know about your profession/ where you work/ how you maintain your current lifestyle? Emergency Contact * Name, Phone Number Have you been to counselling before? * Yes No Prefer not to Disclose Are you under the age of 18? * Yes No If you are under the age of 18, please give information of your parents/ guardians/ caregivers Names (of all parents, caregivers), phone number, and e-mail to reach out for permission If under 18, if there a shared custody agreement? Ex) Are your parents/guardians/caregivers legally separated or divorced? Yes No What is your primary concern for counselling? * Is there anything I should know prior to counselling that would be helpful? * Examples) Accessibility needs, anything that would be helpful for me to be able to fully support you, anything you would like to disclose prior to services How did you find me? Confidentiality * Information shared in a counselling session will be helf in strict confidence. Information will not be released without your written consent, unless required by law. All information is kept in strict confidence unless there is a disclosure of: 1) Child Abuse 2) Threat or aggression/harm to yourself or others 3) A court order is received compelling disclosure Do you consent to the above? Yes No Teletherapy Zoom Video Conferencing uses updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of your communication in session. The Zoom sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I will maintain a record of our session in the same way I maintain records of in-person session in accordance with my policies. Do you consent to the above? Yes No Cancellation Policy * I require a 24 hour notice if you wish to cancel your appointment. If circumstances arise closer to the appointment where you cannot attend, you are responsible for the full fee regardless of insurance coverage. Please note that I *CANNOT* provide a receipt for a missed/ late cancellation appointment. Do you consent to the above? Yes No Extended Benefits or Insurance Reimbursement * Most extended benefits cover Registered Social Workers, but not all. Please check your coverage. By answering, yes, below, you are taking responsibility for the full fee regardless of insurance coverage Yes No Fees * The fee for the 55 minute session is $130.00 CAD. You have the option to pay in cash (if in person), or e-transfer. How will you pay? Cash E-transfer Consent to Fees * I consent to pay PRIOR to the session via e-transfer. All e-transfers must be sent to jennajarviscounselling@outlook.com Do you consent to this? Yes No Signature * By typing your name below, you are consenting to services and policies through Jenna Jarvis Counselling First Name Last Name Thank you!
