T: 604.800.9010
COUNSELLING
INDIVIDUAL
PREMARITAL
COUPLES | MARRIAGE
FAMILY
GROUPS
Group Offerings
Daring Greatly
™
Rising Strong™
Hold Me Tight™
OUR TEAM
Therapists
Gloria Lee
Jennifer Wright
Heather Aikman
Albert Kwok
Laura Brook
BLOG
NEWS
RESOURCES
FORMS
FAQs
CONTACT
LOCATION
REACH US
OUR SPACE
APPOINTMENTS
BOOK TODAY
T: 604.800.9010
COUNSELLING
INDIVIDUAL
PREMARITAL
COUPLES | MARRIAGE
FAMILY
GROUPS
Group Offerings
Daring Greatly
™
Rising Strong™
Hold Me Tight™
OUR TEAM
Therapists
Gloria Lee
Jennifer Wright
Heather Aikman
Albert Kwok
Laura Brook
BLOG
NEWS
RESOURCES
FORMS
FAQs
CONTACT
LOCATION
REACH US
OUR SPACE
APPOINTMENTS
BOOK TODAY
COUNSELLING
INDIVIDUAL
PREMARITAL
COUPLES | MARRIAGE
FAMILY
GROUPS
Group Offerings
Daring Greatly
™
Rising Strong™
Hold Me Tight™
OUR TEAM
Therapists
Gloria Lee
Jennifer Wright
Heather Aikman
Albert Kwok
Laura Brook
BLOG
NEWS
RESOURCES
FORMS
FAQs
CONTACT
LOCATION
REACH US
OUR SPACE
APPOINTMENTS
BOOK TODAY
Resources
Documents and Intake Forms
The following precautions are taken to protect our clients and team members and help slow the spread of COVID-19. Thank you for doing your part in keeping everyone safe!
Office Safety Precautions in Effect During the COVID-19 Pandemic
DOWNLOAD COVID-19
ANNOUNCEMENT HERE
IN- PERSON SERVICES
COVID-19 INFORMED
CONSENT FORM
ON-LINE SERVICES
CONSENT FORM
ON-LINE INTAKE FORMS
Below are options for you.
INDIVIDUAL INTAKE FORM
COUPLE'S INTAKE FORM
MINOR'S INTAKE FORM
PDF INTAKE FORMS
Download these fillable PDF forms and email it back to us.
PDF INDIVIDUAL FORM
PDF COUPLE'S FORM
PDF MINOR'S FORM
Brentwood Counselling Centre
FAQs
INDIVIDUAL INTAKE FORM
INTAKE FORM - BRENTWOOD COUNSELLING CENTRE (INDIVIDUAL)
1. INTRODUCTION
The information you provide here is protected as confidential information. All info will be directed to Gloria Lee of Brentwood Counselling Centre.
Client First Name (Required)
First
Last (Required)
Last
Date of Birth
Age
Gender
*
Male
Female
Address
Address
Address
2nd Address Line
2nd Address Line
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Home Phone
May I contact you via home phone?
Yes
No
Mobile Phone
Email (Required)
May I contact you via your email?
Yes
No
Referred by
Marital Status
Single
Married
Dating
Engaged
Divorced
Common-Law
Separated
Other
Other
Partner's Name
Year of Marriage/Common-Law
Years Together
Year of Separation
Child's Name
Age
At Home?
Yes
No
Child's Name
Age
At Home?
Yes
No
Child's Name
Age
At Home?
Yes
No
Child's Name
Age
At Home?
Yes
No
Child's Name
Age
At Home?
Yes
No
2. HEALTH INFORMATION
Physician
Physician's Full Name
Phone
Physician's Phone Number
Present Medication(s)
Purpose of Medication(s)
In case of emergency, please call:
Relation
Emergency Contact Phone
Psychiatrist
Psychiatrist's Full Name
Phone
Psychiatrist's Phone Number
Mental Health Concerns
Are you currently attending or have attended any groups or other forms of therapy? (AA, Al-Anon, Individual, Couples, Family Therapy, etc.) Please indicate.
3. EDUCATION, EMPLOYMENT
Please indicate your highest level of education:
Elementary
High School
College
University Undergraduate
University Graduate Level
Other
Other
Current occupation:
4. CHURCH, COMMUNITY AFFILIATION
Do you consider yourself to be spiritual or religious?
Yes
No
If yes, describe your faith or belief:
5. FAMILY HISTORY
Briefly describe your family background:
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)
Alcohol Abuse
Yes
No
List Family Member
Drug Abuse
Yes
No
List Family Member
Gambling Addiction
Yes
No
List Family Member
Pornography/Sex Addiction
Yes
No
List Family Member
ADHD
Yes
No
List Family Member
Anxiety
Yes
No
List Family Member
Depression
Yes
No
List Family Member
Suicide Attempts
Yes
No
List Family Member
Domestic Violence
Yes
No
List Family Member
Eating Disorders
Yes
No
List Family Member
Obesity
Yes
No
List Family Member
Obsessive Compulsive Behaviour
Yes
No
List Family Member
Schizophrenia
Yes
No
List Family Member
Other:
List Family Member
6. SELF ASSESSMENT
What was the happiest or best period of your life? (describe)
What was the most difficult or tragic period of your life? (describe)
What are the main problem(s) as you see it?
What have you done to help solve your problems?
What can the counsellor do to help you?
How motivated do you feel you are to solve your problem(s)?
How will you know when your problem(s) are better?
How do you see yourself?
How do other people see you?
How would you like to be seen?
Is there any other information that you think I should know?
7. 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.
Yes, I would like email notifications of new, cancelled, and rescheduled appointments. Client Intial:
NEWS and SPECIAL PROMOTIONS
Yes, I would like to receive news and special. Client Initial:
8. 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 e-transfer. A receipt will be issued for third party reimbursement.
I reserve the right to charge an interest of 15% per month on the total amount owing on accounts that are 2 months or more overdue. You will be given written notice of the balance owing at 1 month overdue. At 2 months overdue, you will be provided with an invoice for the balance plus interest owing.
At 6 months overdue, I reserve the right to use a billing collection agency to recover the balance plus interest owing, and costs incurred with the billing collection agency.
I reserve the right to withhold psychological reports due to the client's failure to pay for professional services rendered. Full payment is required before the report would be released.
I understand and agree to the fees and the payment policy, and to paying all the charges in full at each meeting. Client Initial:
*
9. 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.
I am aware of the Cancellation Policy and agree to pay the late cancellation fee if I provide less than 48 hours notice for any cancellations or changes to my appointment, unless other arrangements have been made with my therapist. Client Initial:
*
10. 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.
I understand and agree to the limits of confidentiality. Client Initial:
*
11. 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.
I understand and agree to the Communication and Termination policy. Client Initial:
*
12. 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.
I allow the disclosure of my counselling sessions for the purpose of supervision. I understand that the purpose of supervision is for the therapist’s professional development and training. I understand that this is a routine procedure in counselling professional development and training.
I have been advised that I have the right to NOT have my clinical sessions discussed and that I may, at any time, change my mind and revoke this consent to have my sessions supervised without affecting my ability to receive treatment. I can revoke my consent by informing my therapist that I do not want future sessions to be supervised.
I have agreed and understand that the content of my clinical sessions and file may be reviewed by my therapist’s supervisor, and that my 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.
I have agreed to and understand that my therapist may case consult about my sessions with other therapists at Brentwood Counselling Centre for the reasons listed above, and that my personal information will be kept confidential and my name will not be used in consultation.
I understand and agree to the supervision and consultation policy. Client Initial:
*
Full Name
*
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.
Date
*
If you are human, leave this field blank.
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