T: 604.800.9010
T: 604.800.9010

COUPLES

INTAKE FORM
COUPLES INTAKE FORM - BRENTWOOD COUNSELLING CENTRE

1A. INTRODUCTION

The information you provide here is protected as confidential information. All info will be directed to Gloria Lee of Brentwood Counselling Centre.
First
Last
Address
2nd Address Line
City
State/Province
Zip/Postal
Country
What is the best way to contact both of you for shared appointments and information?

1B. CHILDREN

1C. PARTNER 1 HEALTH INFORMATION

Physician's Full Name
Physician's Phone Number
Psychiatrist's Full Name
Psychiatrist's Phone Number

1D. PARTNER 1 EDUCATION, EMPLOYMENT

Checkboxes

1E. PARTNER CHURCH, COMMUNITY AFFILIATION

Do you consider yourself to be spiritual or religious?

1F. PARTNER 1 FAMILY HISTORY

1G. PARTNER 1 INFORMATION: In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member in the space provided (self, brother, sister, father, mother, uncle, etc)

2A. PARTNER'S INFORMATION

First
Last
Address
City
State/Province
Zip/Postal
Country
(Leave blank if you share the same address)

2B. PARTNER 2 HEALTH INFORMATION

Physician's Full Name
Physician's Phone Number
Psychiatrist's Full Name
Psychiatrist's Phone Number

2C. PARTNER 2 EDUCATION, EMPLOYMENT

2D. PARTNER CHURCH, COMMUNITY AFFILIATION

Do you consider yourself to be spiritual or religious?

2E. PARTNER 2 FAMILY HISTORY

2F. PARTNER 2 INFORMATION: In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member in the space provided (self, brother, sister, father, mother, uncle, etc)

3.COUPLES ASSESSMENT

4. EMAIL COMMUNICATION

TRANSACTION EMAILS: You can opt to receive emails to keep you informed of new bookings, changes to your bookings, and reminders for upcoming appointments.

5. POLICIES

FEES AND PAYMENT: Fees are payable at the time of each visit, unless other arrangements have been made. You are responsible for payment regardless of third party involvement. If you fall behind in payments for more than two sessions, another session will not be scheduled until your account is paid or arrangements are agreed upon. Fees may be readjusted at any time. One month’s notice will be given for any increase. I charge for time needed to prepare written reports at the hourly rate. Fees are payable by cash, credit or debit. A receipt will be issued for third party reimbursement.

CANCELLATIONS: The psychotherapy process involves meeting for a 1 hour session for individual counselling and 1.5 hour or 2 hour session for couples and families (unless other arrangements have been made). A specific time during the week has been reserved for you. If you must cancel due to illness, please notify me as soon as possible. Should you need to cancel for any other important reason, 48-hour notice is required, otherwise you will be charged for the session. Advance notice gives me time to reschedule and allow someone on the waitlist to be seen.

TELEPHONE CALLS & EMAILS: I check my confidential email and voicemail, (604) 800.9010 daily, less frequently on weekends and holidays. For emergencies, please call 911.

CONFIDENTIALITY: Psychotherapy is confidential except where limited by Canadian law. These exceptions include situations that involve child, elder, or dependent adult abuse or if a client is a danger to him or herself or others. Written permission is otherwise needed to disclose any information to a third party. When working with children and adolescents, it is my policy to regard everything said in session as confidential except where noted above. I will encourage the child or adolescent to disclose to the parent information regarding substance abuse, sexual activity, or other behaviour that places him or her at risk.

TERMINATION: You have the right to terminate treatment at any time. It is helpful for us to discuss termination fully in at least one session. I may also terminate treatment if you do not comply with the conditions of treatment (i.e., coming to sessions clean and sober, refusal to obtain a psychiatric consult, consistent no shows). I may also terminate treatment and refer you to another professional if your issue is beyond the scope of my practice. I understand and agree to the guidelines listed above, to the statement of confidentiality, and to paying all the charges in full at each meeting.

6. CANCELLATION POLICY

CANCELLATIONS : The psychotherapy process involves meeting for a 1 hour session for individual counselling and 1.5 hour or 2 hour session for couples and families (unless other arrangements have been made). A specific time during the week has been reserved for you. If you must cancel due to illness, please notify me as soon as possible. Should you need to cancel for any other important reason, 48-hour notice is required, otherwise you will be charged for the session. Advance notice gives me time to reschedule and allow someone on the waitlist to be seen.

7. LIMITS OF CONFIDENTIALITY

Psychotherapy is confidential except where limited by Canadian law. Your therapist may disclose confidential information without the informed written consent of the client if: a) your therapist determines that disclosure is necessary to protect against a clear and substantial risk of imminent serious harm being inflicted by the client on him- or herself, or on another individual; b) your therapist determines that disclosure is necessary to protect an identifiable child, consistent with applicable law; c) your therapist determines that disclosure is necessary to protect a vulnerable adult who by virtue of condition or circumstance is unable to seek support or assistance for abuse or neglect, consistent with applicable law; d) it is in accordance with any other lawful requirement to do so; e) and if session notes are subpoenaed by the court of law.

Written permission is otherwise needed to disclose any information to a third party.

Your records are stored electronically on Jane App, a Canadian based secured and encrypted filing and booking system.

When working with children and adolescents, it is my policy to regard everything said in session as confidential except where noted above. I will encourage the child or adolescent to disclose to the parent information regarding substance abuse, sexual activity, or other behaviour that places him or her at risk.

8. COMMUNICATION AND TERMINATION

TELEPHONE CALLS & EMAILS: I check my confidential email and voicemail, (604) 800.9010 daily, less frequently on weekends and holidays. For emergencies, please call 911.

TERMINATION: You have the right to end service at any time and to request referral elsewhere. It is helpful for us to discuss termination fully in at least one session.

I may terminate treatment if you do not comply with the conditions of treatment (i.e., coming to sessions clean and sober, refusal to obtain a psychiatric consult, consistent no shows, consistent overdue account).

I may also terminate treatment and refer you to another professional if your issue is beyond the scope of my practice, it is reasonably clear that you no longer need or want the service, or you are not benefitting from the relationship.

Finally, treatment may be terminated when a potential conflict of interest or dual relationship arises, or if I feel threatened or otherwise endangered by the client or another person with whom the client has a relationship.

9. SUPERVISION AND CONSULTATION

It is the policy at Brentwood Counselling Centre to offer supervision to therapists who have less than 5 years of field experience. The purpose of supervision is for the therapist’s professional development and training. It is common practice in the counselling profession to have continual supervision. This process ensures that your therapist is providing the utmost clinical service.

We allow the disclosure of our counselling sessions for the purpose of supervision. We understand that the purpose of supervision is for the therapist’s professional development and training. We understand that this is a routine procedure in counseling professional development and training.

We have been advised that we have the right to NOT have our clinical sessions discussed and that we may, at any time, change our mind and revoke this consent to have our sessions supervised without affecting our ability to receive treatment. We can revoke our consent by informing our therapist that we do not want future sessions to be supervised.

We have agreed and understand that the content of our clinical sessions and file may be reviewed by our therapist’s supervisor, and that our confidentiality will be respected in supervision.

It is also the practice at Brentwood Counselling Centre to offer ongoing consultation for all therapists. This is common practice in the counselling field in order to offer best practices, continued education, and skill development and training of therapists. All client information are kept confidential and names are not used in consultation.

We have agreed to and understand that our therapist may case consult about our sessions with other therapists at Brentwood Counselling Centre for the reasons listed above, and that our personal information will be kept confidential and our name will not be used in consultation.
By typing in your name, you have electronically acknowledged your agreement to all the guidelines and policies listed on this website page and this on-line form.
By typing in your name, you have electronically acknowledged your agreement to all the guidelines and policies listed on this website page and this on-line form.