Intake and Consent Form | Jl Walters Counselli

The information that you fill in is confidential.

At JL Walters Counselling and Therapy, it's important for clients to be aware of policies and procedures before consenting for assessment or treatment. It's important to note that all participation is voluntary. Clients can withdraw from services at any time during treatment. Please take some time to thoroughly read over the policies and please ask if you have any questions prior to agreeing to the terms.

Limits of Confidentiality

Your identifying information along with any information that is accumulated though assessment and or treatment is confidential. There are however, legal limits to confidentiality. Please review the following:

If you are deemed to be high risk of hurting yourself or someone else, confidentially must be broken in order to protect yourself or others.
If children are in your possession and it is thought that they are currently being physically, emotionally or sexually abused, then confidentially will be broken in order to protect the child.
If in the case that a judge orders information from your file, confidentiality must be broken.

Confidentially of children/adolescents:

In order to establish trust among children and adolescents, it is important that the information that is obtained in sessions is confidential. Often children/adolescents disclose information to clinicians that they don’t want their parents to know. If the information is not detrimental to the children’s health or safety and it’s asked to be kept confidential, that will be respected. If however, the child/adolescent discloses information that is detrimental to their health and safety, the child/adolescent will be informed that the information must be disclosed to their parents.

Confidentially between couples in counseling:

At times when working with couples, couples are asked to attend an individual session to accumulate their individual background information. If an individual discloses something to the therapist that they don’t want their partner to know, it will be kept in confidence if it doesn’t pertain to the relationship. If the information does pertain to the relationship then the individual would be encouraged to disclose that information in a joint session.

Payment & Cancellation Policy

JL Walters Counselling and Therapy is a private practice and is not funded by MSI. However, the services offered are covered by many insurance companies. To determine coverage call your insurance company to see if your policy covers Social Work Services.

The fees at JL Walters Counselling and Therapy are $175 an hour for individual therapy and $195 an hour for couples counselling. In order to cancel an appointment without incurring a cancellation fee, I do request 24 hours notice where possible. If an appointment is missed (no show without contact), you will be invoiced for half the amount). Payment is due following each session and expected before the next scheduled session occurs.

Confirmation of understanding of these policies and your consent to confirm your agreement will be reviewed in the initial session before sessions commence.

Thank-you.

Date

First Name

Last Name

Phone Number

Alternative Number

Date of Birth

Address 1

Address 2

City

Province / State

Postal / Zip Code

Country

NS Health Card # and Expiry

Can a personal voicemail be left on your phone? If so what number if you provided more then one.

Would you like relevant health and wellness information emailed to you periodically?

Yes

If referred would you like our office to let this person know you attended our practice?

Yes

How did you hear about our clinic?

Collaboration

A multi-disciplinary team of professionals working collaboratively can provide you with a holistic approach to your health. Your clinician may ask if you would consent to have them correspond with additional members of your health team. Please be aware that this service is on a voluntary basis and you have the right to choose whom your clinician does and doesn't correspond with. Please indicate below who your family physician is and whether or not you consent to allowing me to correspond with them regarding your health. Keep in mind that consent to correspond is voluntary and is not a requirement for access to service.

Who is your family physician?

Do you consent to allowing Walters Counselling and Therapy to correspond with my Family Physician regarding my treatment?

Yes

Acceptance of the terms *

By clicking yes below this indicates you have read the above agreement and had the opportunity to ask any questions related to consent for assessment and/or treatment. I am aware that access to these services is voluntary and at any time if deemed necessary I can withdraw consent to services. By selecting yes I also consent to the verification that I am the one filling out this form.

Yes

Thanks for submitting!