Therapy Intake & Consent Form
This form will help me get to know you, your history, background and presenting concerns. It will take approximately 10 minutes to fill out. 

**Please note all services will be provided virtually**
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PERSONAL CONTACT INFORMATION
First Name *
Last Name *
What are your gender pronouns? *
Email *
What is the best phone number to reach you? *
What is your full address? *
Emergency Contact Name *
Relationship to Emergency Contact *
Emergency Contact Phone Number *
PRIMARY CONCERN
Please describe in your own words the primary issue (s) for which you are seeking therapy: *
How long has the current issue existed? When did it start? *
What would you like the most help with at this time? *
What are your major strengths, or what do you like about yourself? *
Please check which BEHAVIORS recently apply to you: (check off all that apply) *
Required
6. Please check which FEELINGS recently apply to you: (check off all that apply) *
Required
Please check which PHYSICAL symptoms recently apply to you: (check off all that apply) *
Required
What major transitions have you had in the past two years? (i.e. – entering or approaching a new decade of life, a new relationship, a new job, a new role, a new residence, changes in children’s ages/stages of life, separation, divorce, death of a loved one, birth of a child, marriage,  etc.) *
On a scale of 1 – 10, 10 = HIGH, rate your current level of stress: *
Low
High
What would you like your stress level to be? *
Low
High
What are your primary stressors?
On a scale of 1 – 10, 10 = HIGH, rate the quality of your life today *
Low
High
What would you like your quality of life to be? *
Low
High
PHYSICAL & MENTAL HEALTH
Rate your current level of physical health? *
What (if any) medications are you CURRENTLY prescribed for your physical and mental health? *
Please list any medication you were prescribed in the PAST. *
Is there any history of of psychiatric/mental health problems or substance abuse in your family?   *
SAFETY RISK INFORMATION
Have you ever been suicidal or experienced a mental health crisis? *
Have you had any recent thoughts about harming or killing yourself? *
Have you ever attempted suicide? *
Do you have a current plan to harm or kill yourself *
Have you had any recent thoughts about harming or killing anyone else?     *
COUNSELLING AND INSURANCE
Have you had counselling in the past *
Please describe your expectations of counseling. *
What do you hope to achieve in our time together in counselling? (i.e. how will you know you are making progress in therapy?) *
What kind of counselling services are you interested in? *
Required
Anything else you want me to know? *
Will you be submitting your invoice to insurance for reimbursement? *
If so, does your insurance cover the services of a Registered Social Worker (MSW, RSW) in Ontario? *
Will you require direct billing? 

**Please note only certain insurance providers can be billed and only one benefit plan will be processed.**
 *
Name of insurance provider? *
Required
CONFIDENTIALITY AGREEMENT
Information you reveal during our counselling sessions will not be disclosed to anyone outside the session except as outlined below: 

1) You consent in writing                                                      

2) Life or safety is seriously threatened; including suspicion of harm to yourself, others and child abuse 

3) Disclosure is required by law;                                                            
*
FEES AND CANCELATION POLICY
Fee's are charged at $159 a session. 

I acknowledge I will be invoiced and expected to pay for the session (or the outstanding balance) on the day of the session before my session starts (via e-transfer). 
 *
Please notify me (at jodi@creatingnewsteps.com) if you need to cancel or re-schedule your session prior to 24 hours of your session. 

Should you choose to miss a session without notification of at least 24 hours you will be invoiced and charged the full fee of the session.
 *
Receipts for insurance will be issued following the attendance of your session and in the amount you paid for the session. *
OTHER
How did you hear about our practice (Creating New Steps)? *
Would you like to subscribe to my emails to get mental health tips and information on upcoming groups/workshops.

I promise not to spam your inbox!
 *
Please print your name below to indicate you understand everything outlined in this form. Should you have any questions feel free to email jodi@creatingnewsteps.com 
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