Child Intake Questionnaire
Rates for Services are: $235/Hour (Amanda) - $200/Hour (Tiffany) - Effective May 1, 2025
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Email *
Date: *
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Therapist Requesting: At this time, Amanda is not accepting any new clients.  Please contact Rachel Brushett, Office Manager at rachel.brushett@icloud.com before completing this questionnaire.  If you have already spoken to Rachel, please go ahead and complete the intake. *
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Client Name: *
Client's Date of Birth *
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Age: *
Are the parents together?  If not, we will need consent from the other parent.  Please be aware that if the parents are not together we always try to have complete transparency and both parents will be made aware of appointments. *
Parent/Guardian/Caregiver #1 (Name) *
Parent/Guardian/Caregiver #1 (Phone Number) *
Parent/Guardian/Caregiver #1 (Email) *
Parent/Guardian/Caregiver #2 (Name) *
Parent/Guardian/Caregiver #2 (Phone Number) *
Parent/Guardian/Caregiver #2 (Email) *
School:
Family Physician:
Psychiatrist (if applicable)
Email (for billing purposes) *
Who referred you to our services? *
Are both parents aware of the services requested? *
Are there any custody issues/lawyer involvement: *
If yes, is there a parenting order or custody agreement in place?
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Has there been or is there any upcoming court/mediation process? *
If yes, how many? Please explain.
If there are lawyers involved, please be aware that we have all parties sign a "Collaborative Agreement" as counselling for the child(ren) is for therapeutic reasons only, not for court purposes.  Services will not commence until such agreement is signed by all parties involved.
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What would be the main reason you are seeking psychological services for your child(ren)? *
Amanda hours currently are: Monday & Tuesdays (9:15am, 10:45am, 1:15pm, 2:15pm and 3:30pm), Wednesdays (1:15pm, 2:15pm and 3:30pm) Thursdays (1:15pm, 2:15pm and 3:30pms).  **Please be aware that since Amanda sees a lot of children that the 3:30pm appointments are the first to go.  Are you ok with other times of the day for your child to be seen? *
Is your child currently seeing another counsellor? *
Has your child had counselling before, if yes with who and what was the outcome? *
Any other information you would like to share?
**Please know that we are able to direct bill most insurance companies, should you have one.  However, we always recommend that you contact your insurance company prior to your first appointment to find out 1) if direct billing is available 2) how much you are eligible for annually 3) how much you are eligible for per session.  This way there is no surprises.  If you have an insurance company, please advise which insurance company it is. If you do not have one, please just write "none" *
Member's Name of Insurance Company
Member's Date of Birth of Insurance Company
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Member's Plan/ID #
Member's Group #
Child's Plan/ID# 
Consultation Agreement - Please click the link below and take the time to read through our consent at the bottom of the page prior to your first appointment so that if you have any questions or concerns, that you can bring them up to your therapist.
https://www.solfocpsy.ca/services 
Thank you for taking the time to fill this out, it really gives us a snapshot of what you would like help with for your appointments.
Should you need to contact our office you can do so by calling (403) 504-9777 or via email at rachel.brushett@icloud.com
A copy of your responses will be emailed to the address you provided.
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