Intake Form & Counselling Agreement

Today's Date *
Today's Date
Therapist
Therapist
Name *
Name
Address *
Address
Phone *
Phone
Are Messages OK *
I provide permission to CCS to communicate with me/us via email to receive updates, etc
Birthdate *
Birthdate
Work Phone
Work Phone
Emergency Contact *
Emergency Contact
Emergency Contact Number *
Emergency Contact Number
Have you attended counseling previously?
Cancellation Policy *
We kindly ask you to provide us with at least 24 -48hours of notice if you intend to cancel your appointment. PLEASE NOTE OUR ACCOUNTS DEPARTMENT WILL AUTOMATICALLY SEND YOU AN INVOICE IF YOU WERE UNABLE TO CANCEL YOUR APPOINTMENT IN A TIMELY MANNER Check below to confirm that you have read and agreed to our cancellation policy
Who is a
to provide counselling consultation, assessment, and/or treatment to me/ua *
Training Centre – Practicum & Internship Program - CCS Interns
CCS is also a training centre providing clinical training to Doctorate and Masters level students who are in the process of finishing their degrees. Our interns are under the supervision Dharshini Chanderbhan or another Doctorate or Masters level therapist. One method of assisting our interns to refine their skills as a therapist is to audio and/or video tape their sessions or perform co-therapy with their supervisor. If interested, we would require your consent to use audio or visual devices during your session. (Please note these sessions will be used for educational purpose only and will be erased after review). Below please check any that apply
I understand that their internship is time limited therefore, they will do their best to provide treatment until the client’s goals are achieved. In cases where the internship is completed, I understand that my file may need to be transferred to another CCS intern.
Insurance Coverage and Fees *
Psychotherapy services are not covered by O.H.I.P., but are often partially or fully covered by extended insurance plans. Coverage plans differ, so please check with yours regarding coverage and claim procedures (e.g., whether or not a letter or referral from your physician is required, details required on receipts, etc.).. We are not covered under Registered Psychologists, only Registered Psychotherapists. Please note that Manulife does not cover Chanderbhan Counselling Services. Referrals need only state, “I refer (client name) for psychological consultation or assessment.” Payment for services is due at the beginning or end of each session and a receipt will be given when payment is received. Please retain this receipt for your insurance or income tax claims, if applicable. Fees vary according to the time, therapist and nature of the service involved. Your fee will be discussed with you during the intake interview and you will be provided with reasonable notice beforehand if any changes are made to the fee. Fees may be paid by cash, cheque, VISA or Master Card. A surcharge of $25.00 will apply to all N.S.F. cheques. A late payment fee of 2% per month will be added if payment is not received after 30 days of the date of service. Outstanding accounts of more than 60 days will be eligible for submission for collection. Click below to confirm that you have read and understood the above
Confidentiality *
Confidentiality is respected at all times. No information will be communicated, directly or indirectly, to a third party without your informed and written consent. Exceptions to confidentiality include the legal and/or ethical obligations to: • Inform a potential victim of violence of a client’s intention to harm • Inform an appropriate family member, health care professional, or police if necessary of a client’s intention to end his or her life • Release a client’s file if there is a court order to do so • Inform the Children’s Aid Society if there is suspicion of a child being at risk or in need of protection due to neglect, or physical, sexual, or emotional abuse • Report a health professional who has sexually abused a client Click below to confirm that you have read and understood the confidentiality information
Privacy of Personal Information *
I understand that in order for CCS, one of its associates and/or a supervised non-registered service provider to provide me with counselling services, they will collect some personal information about me (e.g., name, address, telephone number, health history, and social situation) in order to help assess what my needs are. This information will then be used to advise me of my treatment options and to help me receive the treatment I choose. I understand that in the course of business, office staff may need to access some of my personal information (e.g., address for billing purposes, extended insurance information) and that this access is limited. I understand that I have the right to review and the right to a copy of my personal information, barring a few rare exceptions. A complete copy of the privacy policy is available upon request. Check below to confirm and understand the privacy of personal information
In case of emergency & Satisfaction Policy
In Case of an Emergency Emergency services are not available. In the case of an emergency, clients should dial 911, contact their Family Practitioner, or go to the Emergency Department of any hospital. At CCS we understand that creating a strong therapeutic alliance is essential for successful therapy. With this in mind, if you do not feel connected to your assigned therapist, please inform our intake department (Ext. 1) or Dharshini Chanderbhan (Ext. 2) about your concerns and they will gladly connect you with another therapist that will meet your needs.
Informed consent *
By checking the box below this confirms that: I have read and understood the information presented in this document, and hereby consent to counselling, coaching and/or psychotherapy treatment I understand how the Privacy Policy at CCS applies to me and have been given a chance to ask any questions I have about the privacy policies and practices and they have been answered to my satisfaction. I agree to allow CCS to collect, use, and disclose personal information about me as set out above and in the CCS’s Privacy Policy.