Anna's New Client Intake & Liability Waiver Form
PLEASE READ AND FOLLOW INSTRUCTIONS TO BOOK AN APPOINTMENT

1) Please READ below, EACH question MUST be FILLED otherwise the form won't be submitted.

2) TEXT 587-645-0880 to make an appointment with Anna Lisa

Appointment reminders are sent via email and text 24 hr before your appointment.

Please note that there is a cancellation and no refund policy in effect listed below.

By filling out this form you are accepting this waiver & release of liability & all of the terms and conditions indicated below. Thank you.

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Email *
First Name *
Last Name *
Mobile Number *
Street Address *
City, Province, Postal Code *
Gender *
Birthday *
MM
/
DD
/
YYYY
How did you find Anna of who referred you? *
Check all that apply *
Required
If /When employed where do you work and what type of work do you do? *
Check all that apply *
Required
If you are going to school where and what are you taking? *
Highest education completed: *
Emergency Contact, Phone Number, Email & Relationship to you *
Please list significant medical problems/conditions/injuries, surgeries, allergies, and indicate if you are receiving treatment for them: *
Do any of these problems affect your everyday life? If yes, how so? *
List any medications you are on & what they are for *
Name and contact of your current Primary Care Physician: *
Name and contact of your current Psychiatrist: *
Have you ever had previous therapy/counselling of any kind? If yes, when, with whom, and for how long? *
Please check all of the items below that describe your situation: *
Required
Please briefly describe the problems/concerns you are experiencing? *
What has happened to cause you to seek help now? *
What do you hope to be able to do/achieve as a result of treatment? *
How do you handle stressors and/or cope with the problems you described? *
Are you in a moderate to high risk abusive relationship? Please explain. *
If you are interested in spiritual guidance/modalities or currently on a spiritual journey please advise if you also take recreational drugs or have. Please describe below.  *
Do you currently have thoughts of harming yourself? *
If yes to the above, Are you receiving treatment/mental health support for it? *
Do you currently have urges to hurt, harm someone else? *
If yes to the above are you receiving treatment/mental health support for it? *
Have you had thoughts of harming yourself or someone else in the past? If yes, how long ago, and did you receive treatment/help? *
Have you ever been hospitalized for emotional problems? If yes, please note when, where and for how long you were hospitalized. *
Have you ever been hospitalized for substance abuse problems? If yes, please note when, where and for how long you were hospitalized. *
Have you experienced a problem with alcohol, drugs, or prescription medication? If yes, please explain: *
Have you ever been treated for problems with alcohol, drugs, or prescription medications? If yes, please explain: *
Has anyone (family, doctors, friends, coworkers, bosses, etc.) ever expressed concerns that you might have problems with alcohol or drugs? If yes, please explain: *
Have you had any problems relates to use of alcohol/drugs in the past year? If yes, please explain: *
Has drinking or drug use ever caused you problems in the following areas (check all that apply if yes): *
Required
Have you been charged for any type of assault or domestic abuse charges? *
Have you been mandated by the courts to seek counselling? *
If you answered yes to: “currently having thoughts of harming yourself or others and/or being charged for assault or domestic abuse, and/or mandated by courts, and you are involved an abusive relationship" or you are moderate to high risk you will immediately be referred to other mental health services or other professionals that can assist you further. In the event any of the criteria above occurs during therapy you will be immediately referred to mental health services or other professionals that can assist you further. Do you agree to these terms? *
What is your availability (please be specific for accommodation) *
LIABILITY WAIVER & TERMS & CONDITIONS. MUST READ.
​​ACKNOWLEDGMENT OF SERVICES WITH ANNA LISA OF INFINITE STRENGTH 

I understand that Anna Lisa Trillana of Infinite Strength is a Registered Psychotherapist, CCC, CT, RPC, CCTP-1, and Integrated Life Coach.

I understand that Anna Lisa Trillana of Infinite Strength provides other holistic modalities and she is a Certified Clinical Hypnotherapist; Certified Hearth Math+ Practitioner; Certified Master/Instructor in Usui Reiki; Kundalini Reiki, Celtic Reiki, Huna Reiki, Hot Stone Reiki, Lightarian Enlightenment Rays Reiki, Karuna Ki Reiki, Shamballa Reiki, Seichim Reiki; Integrated Energy Therapy® Angel Therapy, a Registered Certified Yoga Teacher, Certified Sound Coach, Licensed Spiritual Coach, Spiritual Response Practitioner SRT/SpR, Qi Gong teacher/practitioner and MDS (TM) practitioner. Soul Contract Reader, Higher Light Lotus Sword Lightbody Practitioner and the owner and facilitator of ISO(TM) courses that may involve dowsing, boundaries, wound and shadows and more. She may incorporate any of these modalities during individuals session via in-person, phone or online sessions if we have agreed upon the integration of it. Specific Spiritual Energy Sessions ie: Soul Contract Readings are not claimable under your insurance, only counselling sessions are claimable under your Counselling Insurance Benefits. 

I understand that the above modalities can assist me in:

•    Learning how to relax to reduce stressors 
•    Refocus my thoughts to regulate my emotions 
•    Breathing Techniques, Meditation, Managing my pain
•    Improve my mental functioning & enhance the quality of my life through recognizing my inner tools and resources to be more empowered to make more informed decisions about my health and well-being in a more positive direction
•    During Certified Courses she will coach me, train me, empower me, explain, instruct, mentor, quiz for knowledge, supervise, teach and test for knowledge

PROFESSIONAL THERAPEUTIC RELATIONSHIP GENERAL INFORMATION

I understand this is a professional therapeutic relationship and it is uniquely and highly personal, but at the same time is a contractual agreement. Given this, it is important for us to reach a clear understanding of how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. 

I understand that Anna Lisa Trillana of Infinite Strength cannot promise that my behaviour or circumstance will change, however, I understand she will do her very best to understand me and any repeating patterns, as well as provide clarity through paraphrasing and summarizing my dialogue. 

I understand that my goal plan depends largely on my willingness to engage in this process, which may at times, results in considerable discomfort.

I understand that counselling therapy can expose me to experience emotional issues while I am healing myself in any of my sessions with Anna Lisa Trillana of Infinite Strength, and remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures, nor can I blame my discomforts as I have understood that it is part of the therapeutic process.

I understand that Anna Lisa Trillana of Infinite Strength is not to be used as a scapegoat during/outside of session time, therefore I understand that I will not blame her in person or other forms of communication such as emailing/texting her inappropriately for a discomfort experienced during/outside session time.

I understand that counselling involves Anna Lisa Trillana and myself working together as a team; to help me to learn to regulate my emotions and effectively communicate with others and self realize. Thus, seeking Anna Lisa Trillana's opinion/validation is contradictory to therapy. 

COUPLES THERAPY

I understand that should I want to switch from an individual counselling relationship to a couples counselling relationship or vice versa the format of counselling shall change. I understand that couples counselling will sometimes involve 1-on-1 sessions with each partner to incorporate a broader view of the relationship concerns, however, any individual/couples work may have to be referred to another counsellor depending on the agreement between myself and Anna Lisa Trillana of Infinite Strength, to avoid conflict of interest in the couples therapeutic relationship.

I understand that Anna Lisa Trillana of Infinite Strength is not to be used as a scapegoat during/outside of session time, therefore I understand that I will not blame her in person or other forms of communication such as emailing/texting her inappropriately for a discomfort experienced during/outside session time.

I understand that I will not seek to take my partner to couples counselling to receive validation from Anna Lisa Trillana of Infinite Strength if my beliefs are right or wrong. I understand that couples therapy involves Anna Lisa assisting my partner and me to learn to communicate more effectively. Thus, seeking Anna Lisa's opinion/validation is contradictory to therapy. Lastly, I also understand that Anna Lisa will refer me to other therapists for any parenting issues that may arise. 

GROUP CLASSES/WORKSHOPS IN-PERSON & ONLINE

Group Classes & Workshops can be a powerful and valuable venue for healing and growth. It is the desire of Anna Lisa/Andrew that you reap all the benefits the group has to offer. To help this occur, groups are structured to include the following elements:

- A safe environment in which you are able to feel respected and valued as you work
- An understanding of group goals and group norms
- Investment by both Anna Lisa/Andrew and members to produce a consistent group
experience

A safe environment is created and maintained by both Anna Lisa and its members. The primary ingredients are mutual respect and a chance to create trust. Another primary ingredient for a safe environment has to do with confidentiality. We realize that you may want to share what you are learning about yourself in a group with a significant other. This is fine as long as you remember not to talk about how events unfold in a group or in any other way compromise the confidentiality of other group members. Classes may be recorded with the permission and request of the members and are to only be shared with the group members, this is not always available, however, Anna Lisa will discuss previous to the class starting if a recording will be made available to the group members.

I understand that group therapy/courses can expose me to experience emotional issues while I am healing myself in the group setting, and remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures, nor can I blame my discomforts as I have understood that it is part of the group therapeutic class process.

SELF-CARE EMERGENCIES

I understand I will make use of the resources below if I need to discuss concerns outside my appointed session. If at any time I feel like harming myself or injuring another, I will let the group leaders know and or contact my individual therapist or psychiatrist. If I cannot reach them, I will call either 911 or the Crisis Line at 1-877-303-2642 (24hr Crisis Line) or go to the nearest emergency care centre in my local area.

I also understand and accept that the counselling relationship with Anna Lisa Trillana of Infinite Strength will be terminated immediately should I require further mental health or other professional authorities’ assistance if there is a disclosure of suicide ideation or domestic violence. A safety plan, referrals to licensed professionals and services will be provided to me and if necessary authority measures will be acted upon to ensure my safety.

TELEPHONE ACCESSIBILITY

I understand that if I need to contact Anna Lisa Trillana between sessions, I can email her and I understand that she will reply within 36 hr during business days. 

There will be NO TEXTING for any issues, concerns or questions. TEXTING IS ONLY FOR APPOINTMENT SCHEDULING.

I understand that Anna Lisa is not often immediately available; however, I understand Anna Lisa Trillana will make the attempt to return my call/email within 36 hours. Hence I will make use of the after-hours/after-session resources (SOS Crisis Line, 911, and local emergency facilities).

Any messages sent after Friday 9 pm – Sunday 6 pm. I understand they will not be reviewed till Monday. I understand that it is best to discuss concerns at my appointed session. 

ELECTRONIC COMMUNICATION

I understand that Anna Lisa Trillana cannot ensure the confidentiality of any form of communication through electronic media, including text messages. Communication via email or text messaging is only permitted for issues regarding scheduling or cancellations; while Anna Lisa Trillana may try to return messages in a timely manner within 36hrs during business times, Anna Lisa Trillana cannot guarantee immediate response and request that you do not use these methods of communication to discuss counselling content and/or request assistance for emergencies.

MINORS

I understand that if I am a minor, my parents may be legally entitled to some information about my therapy. Anna Lisa Trillana will discuss this with me, and my parents about what information is appropriate for them to receive and which issues are more appropriately kept confidential.

ONLINE SESSIONS/TELE-COUNSELLING

Tele-counselling refers to counselling services that remotely use telecommunications technologies, such as video conferencing or telephone. One of the benefits of tele-counselling is that the client and the counselling can engage in services without being in the same physical location. Although there are benefits of Telepsychology, there are some differences between face-to-face counselling and Tele-counselling, as well as some risks. For example: 

Because the Tele-counselling sessions take place outside of the private office, there is potential for other people to overhear sessions if you are not in a private place during the session. As your therapist, Anna Lisa will take reasonable steps to ensure your privacy but it is important for you to make sure you find a private place for the session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other devices. You should participate in Tele-counselling only while in a room or area where other people are not present and cannot overhear the conversation. 

There are many ways that technology issues might impact Tele-counselling. For example, technology may stop working during a session, other people might be able to get access to our private conversations, or stored data could be accessed by unauthorized people or companies. Your coach has a legal and ethical responsibility to protect all communications that are a part of Tele-counselling, for example ensuring that the platform used is PHIPA compliant. 

As your therapist, Anna Lisa has the right, at any time, to determine if Tele-counseling is not appropriate for your situation. Should this be determined, I will provide you with referral information to other, more suitable, services.  Confidentiality:  The extent of confidentiality and the exceptions to confidentiality outlined in this Informed Consent document apply in Tele-counselling; 

When engaging in a Tele-counselling session, please also keep the following in mind: -ensure you are in an appropriate location (free of distractions like family and pets if possible); -verify ahead of time the best reception in your chosen location; -dress appropriately as you would for a session; -refrain from eating and/or smoking during the session as these can create communication challenges. 

TERMINATION OF COUNSELLING RELATIONSHIP

Ending relationships can be difficult. Therefore, it is important to have an appropriate termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment decided by both Anna Lisa and myself. 

Anna Lisa Trillana may terminate counselling with me if our therapeutic relationship/counselling sessions are no longer suitable, appropriate or beneficial; recommendations to other professionals can be provided to me if needed. If Anna Lisa Trillana determines that the therapy is not being effectively used by me, if our therapeutic relationship is not in alignment, or if I am in default on payment, Anna Lisa Trillana will discuss the purpose of terminating with me. 

If counselling is terminated for any reason or you request a different therapist, Anna Lisa Trillana will provide you with a list of qualified therapists to treat you. I understand I may also choose someone on my own or from another referral source. 

I also understand and accept that the therapeutic relationship will be terminated immediately should I require further mental health or other professional authorities’ assistance if there is a disclosure of suicide ideation or domestic violence. A safety plan and referrals to professionals and services will be provided to me and if necessary authority measures will be acted upon to ensure my safety.

Should I fail to schedule an appointment or communicate with Anna Lisa Trillana for two consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, Anna Lisa Trillana must consider the professional relationship discontinued.

ACCEPTANCE OF INFORMED CONSENT

I agree that I am here on my own behalf and not as an agent for any federal, provincial, municipal or professional agency on a mission of entrapment or investigation. By signing below, I further agree that I will not hold Anna Lisa Trillana of Infinite Strength responsible should there be any unfavourable outcome or result. I have read the above-noted consent and have had the opportunity to question the contents and my therapy. By agreeing to this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed and any additional treatment as proposed by my therapist to deal with my physical condition(s) for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.

GOVERNING LAW & JURISDICTION

These Terms and any dispute or claim arising out of or in connection with their subject matter or formation, including non-contractual disputes or claims, shall be governed by and construed in accordance with the laws of the Province of Alberta and the laws of Canada applicable therein. You agree that the courts of the Province of Alberta shall have exclusive jurisdiction to settle any dispute or claim arising out of or in connection with the subject matter or formation, including non-contractual disputes or claims, of these Terms.

PAYMENT POLICY/CC ON FILE

I understand to hold my appointment Anna Lisa Trillana of Infinite Strength requires a CC saved on file. I agree to prepay on the day of my appointment with the credit card that is also on file. 

 I also agree that It will not be charged UNLESS I have a no-show appointment or I have unpaid/outstanding sessions on file or schedule changes/cancellation is made less than the 24 hours notice policy.

I understand that prices are subject to change at any time and it is MY responsibility to review prices on the website to confirm I am paying the correct amount for my appointment.

I understand that Infinite Strength is a private clinic and does not do any direct billing.

I understand that should I choose to purchase a package they have an expiry from the date of purchase based on the package purchased.

I understand that: 

1-ON-1 sessions are NOT applicable to 2-ON-1 sessions. If one client doesn't show up for the 2-ON-1 booked session it is still considered a 2-ON-1 session. 

EXPIRY OF PACKAGES POLICY

5 sessions: 2 month
10 sessions: 3 month

(Monthly appointment intervals- the expiry dates are subjected to a different timeline that is agreed upon by Anna Lisa & me)

TIME OF SESSIONS & PUNCTUALITY:

I understand that the time of sessions involves:

Sessions are 50 minutes in length. Sessions with Anna are 50 min and the remaining 10 min for administration.

I understand that I must be on time for my appointment and there will be no extra time provided at the time the session is scheduled to be over.
​​
I understand that if I am not prepared for my zoom online session (driving, at a public place, or a compromised location that doesn't allow confidentiality privacy) the session is terminated immediately.

If I am late for a session or not appropriately prepared for our zoom online session, I understand I may lose some time during that session time. 

OR 

if it is a disruption to the session it can conclude in a loss of session (ie. 20-30 min left in a session is not sufficient for counselling & discussing matters that require more processing time)

NO REFUND POLICY IS IN EFFECT 

I understand that there is no refund policy in effect. I also understand and accept that expired sessions will not be refunded or honoured. 

For any courses, I am only exempt to transfer ONCE to the next available course date. 

Clients are responsible to keep track of their sessions remaining.  

Please contact info@infinitestrength.ca to get receipts, payments settled, and session balance. 

CANCELLATIONS, NO-SHOW POLICY & PUNCTUALITY

I understand and agree that I must provide at least 24 hours' notice of cancellation or re-scheduled session or I forfeit the value of that session. i.e. I will be charged on the CC I have on file/lose a session from my package purchased. 

A charge of $80 plus tax will be charged if there is no package purchased. I authorize my credit card information to be charged for the $80 plus tax Cancellation Fee based on these conditions.

If you as the Client or Anna Lisa your Therapist is sick there is no cancellation fee charged, and vice versa Anna as your therapist does not owe the client if they had to cancel under short notice due to being sick. Any other reasons for cancelling either party will incur the cancellation fee charge or make session (no charge to the client) will be provided for the next session.  

I understand that this is necessary because of the time commitment made for me and it is held exclusively for me. 

PRIVACY POLICY

Anna Lisa of Infinite Strength collects, uses and discloses health information according to the Personal Health Information Privacy Act Infinite Strength is committed to taking steps to protect your personal health information from theft, loss and unauthorized access, copying, modifications, use, disclosure and disposal and to protecting your privacy and only using your personal health information for the purposes you consent. Infinite Strength cannot reveal information about me without my written permission except where disclosure is required by law: “If I present an imminent threat to myself or others; When there is an indication of abuse of a child, elder or dependent adult, If I become gravely disabled; By court subpoena.

CONFIDENTIALITY & RESPONSIBILITY

I understand that I am responsible for my own health, healing and wellbeing. I also understand I have the ability to heal myself by reconnecting to the Source of all healing I understand it is my responsibility to advise Anna Lisa Trillana of anything that might help us work together better to achieve the healing I seek. I further understand any services performed by Anna Lisa Trillana are not a substitute for adequate medical care and I intend to remain under the care of my primary healthcare provider.

I understand that if I have -- or if I think I have -- a medical/psychological or emotional concern, condition, disease, disorder, issue or symptoms, Anna Lisa Trillana will help me reduce any related stress and consult with or refer me to other professionals in their areas of expertise in order to provide the best treatment for me.

I understand that Anna Lisa Trillana will seek required law & medical attention/other professionals when my health and safety are in jeopardy; or I present an imminent threat to myself or others; or if there is an indication of abuse of a child, elder or dependent adult; or if I become gravely disabled.

I agree that I am here on my own behalf and not as an agent for any federal, provincial, municipal or professional agency on a mission of entrapment or investigation.

I understand if we see each other accidentally outside of the therapy office, Anna Lisa Trillana may not acknowledge me first. It is my right to privacy and confidentiality and is of the utmost importance to Anna Lisa Trillana, as they do not wish to jeopardize your privacy. However, if I acknowledge Anna Lisa Trillana first, she will be more than happy to speak briefly with me, however, Anna Lisa Trillana feels it appropriate not to engage in any lengthy discussions in public or outside of the private office. I understand that despite our professional therapeutic relationship is created and incorporates a connection of rapport and trust, please remember Anna Lisa is not your "friend" but your "professional" providing you with a service. Friends reach out personally to each other they do not engage in "professional therapy sessions" and Anna Lisa does not reach out personally to me.

ONLINE SESSION/CLASS ETIQUETTE/BOUNDARIES
IN-PERSON PROFESSIONAL STUDENT ETIQUETTE/BOUNDARIES
To hold your appointment we must have a CC safely stored on file this also ensures there are no outstanding sessions unpaid on your account. CC's are safely secured & will ONLY be charged for "No shows/late cancellations or unpaid session(s)" * terms & conditions*. If you prefer to tell Anna Lisa or Ethan over the phone you can type that in the box below. Thank you.                                                                 
Name on CC -- CC # -- EXP# -- CVV# -- Postal Code
*
I have read all the terms & conditions above. I have filled out the information requested as 100% accurate and to the best of my knowledge. I accept this waiver & release of liability including all the terms and conditions indicated on this form. *
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