Equal Counselling & Coaching
INTAKE AND CONSENT FORM
Monique Verhoef, Registered Therapeutic Counsellor (#2201)
First and Last Name *
Address and Postal Code *
(Cell) Phone and Email address *
Date of Birth *
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Emergency Contact and Relationship *
Do you have any thoughts of harming your self or others? *
INFORMATION FOR PET LOSS (if applicable)
Pet's name
Age
Date of death
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Circumstances of loss
CONSENT
All our communication and what happens in the session becomes a part of your clinical record. Keeping files allows me to work with you in a planned organized manner tracking goals and progress. The records are kept under lock en key in a secure location. I am under clinical supervision with an experienced and qualified therapist. If I need to discuss therapy with a professional colleague, or in any other professional context, your identity will be disguised. In all counselling relationships, there is an adherence to a strict standard of confidentiality. No information given by you to your counsellor will be disclosed to a third party without your consent. Client files are privileged and confidential.
Teletherapy: Prior to starting video-conferencing services, we discussed and agreed to the following: There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions. Confidentiality still applies for telepsychology services, and nobody will record the session without permission from the others person(s).
Exceptions to confidentiality: There are a few exceptions to confidentiality. A therapist is required to maintain client confidentiality, except where there is written consent, danger to self or others or as required by law. A therapist is required to report the sexual or physical abuse of a child to the authorities: 1. If the counsellor thinks any person’s life or health is in imminent danger, he/she is ethically and legally bound to take appropriate action. 2. Under B.C. law, if the client suggests that a child, elder or disabled person may be reported to the Ministry of Children and Family Development and/or police. 3. In extraordinary circumstances, the courts have discretionary power to subpoena or court order files, cases notes and/or obtain counsellor notes. 4. The client directs the counsellor to share information with another person.
First name and Last name *
Date *
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