Intake FormPlease fill out the attached intake form so that we may get to know you better. Fields marked with an* are required.Contact InformationName* First Last Email* Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City Province Postal Code Phone*Emergency Phone*Relationship to Emergency Contact*Client InformationPlease fill out the information below to the best of your knowledge.Reason for Seeking CounselingReferred by (please indicate N/A if no referrals)What issues would you like to work on during therapy?Have you engaged in therapy before? If yes, for how long and for what reason? (Please indicate N/A if this is your first time)Medical HistoryThe information gathered from this section is meant to inform the therapist of any underlying conditions and will be discussed further during the initial in person session.Are you currently on any medication?YesNoIf yes, please indicate nameFrequencyFamily Doctor’s nameDo you use recreational drugs?YesNoIf yes, how frequently?Any other supplements?YesNoPlease indicate which supplements, if any.Any underlying medical conditions which you would like to let us know about?Informed Consent (In-person and distance counseling)Informed consent is an important legal concept in health care and is set out in the Health Care Consent Act, 1996. Prior to the intervention of a therapeutic, diagnostic, preventive, palliative or other health related purpose, practitioners are required to obtain informed consent from prospective clients and during the entire duration of the therapeutic process.In-person counseling occurs in the physical presence of a therapist/practitioner. Distance counseling occurs through video conferencing technology or by phone. Distance counseling is useful if you would like to engage in psychotherapy and the psychotherapist is not located in your area.Risks and BenefitsLike all forms of counseling, distance and in-person counseling possess both benefits and some risks. Risks may include, but are not limited to, experiencing feelings such as stress, sadness, guilt and frustration. In addition, clients may not agree with a therapist's assessment, diagnosis, case formulation or treatment. Benefits of counseling may include improved social interactions, improved mood, the resolution of personal problems and improved psychological well-being.BenefitsBenefits of distance counseling may be comparable to those in a traditional face-to-face counseling relationship - the building of a therapist-client therapeutic alliance designed to assist a client in his/her personal growth and life issues. However, with the use of telephone, a psychotherapist may be limited in that he/she is unable to take into account the visual or non-verbal cues of a client. Video conferencing is the preferred method of Distance Counseling, but it too might have some limitations associated with the therapist and client not being able to effectively communicate feelings and emotions. You should weigh the benefits against the limitations of services before consenting to the distance counseling process.I am aware of the limitations, risks and benefits of distance counseling. My signature/initials in the box below indicates consent to engage in Counseling.Signature*ConfidentialityConfidentiality is an important legal concept that is applicable to all regulated health professionals. As per the Personal Health Information Protection Act, 2004 (PHIPA) personal health information is to be kept confidential and secure. Personal health information is identifying information about a client which is either in verbal, written or electronic format. Limits to confidentiality include the following; 1) Disclosure is necessary in order to eliminate or reduce significant, imminent risk of serious bodily harm (includes physical or psychological harm) to the client or anyone else. Note: if the psychotherapist believes a significant imminent risk of serious bodily harm exists (this includes physical or psychological harm), there may be a professional and legal duty to warn the intended victim to contact relevant authorities, such as the police, or to inform a physician who is involved in the care of the client. 2) Under the Child and Family Services Act, 1990 for example, where the member has reasonable grounds to suspect that a child is in need of protection due to physical harm, neglect or sexual abuse by a person having charge of the child. 3) Where necessary for particular legal proceedings (e.g. when the member is subpoenaed) 4) to facilitate an investigation or inspection if authorized by warrant or by any provincial or federal law 5) to a college for the purpose of administration or enforcement of the Regulated Health Professions Act, 1991My signature/initials indicated in the box below indicates agreement to the Limits of Confidentiality.Signature*Cancellation PolicyYour appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the therapist's day that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Client who provide less than 24 hours notice, or miss their appointment, will be charged a cancellation fee.I am aware of and agree to the Cancellation Policy.Signature*Record KeepingClient records will be maintained and stored by Basanti Counseling in a safe and secure manner. Clients have the rights to access their records and to correct errors in them. Records will be maintained in English and should the client not be satisfied with the way in which the record was maintained or shared, a complaint can be filed with the College.My signature/initials below indicate that I am aware of and agree with the Record Keeping process.Signature*Release of InformationInformation about clients will not be released to anyone except when clients provide consent. It is expected that Registered Psychotherapists will collaborate and maintain positive working relationships with other professionals encountered in practise. This is limited to other health care providers in which the client provides consent for the information to be shared with. Communication can be in the form of phone conversations, written communications, meetings requested by the client. Such communication will be documented in the clinical record.My signature/initials below indicate that I am aware of and agree with the Release of Information.Signature*CommentsThis field is for validation purposes and should be left unchanged.