New Client Intake Form

Please take a few moments to fill in all sections that apply to you. Sections with a  *  are essential and your information will not be shared with anyone.

Name *
Name
Cell Phone *
Cell Phone
Home Phone
Home Phone
Home Address *
Home Address
Confidentiality Agreement - Please carefully review the following information. Confidentiality is an important aspect of your counselling, so please feel free to ask any questions at any time. Counsellors have a primary obligation to respect the confidentiality of information obtained from persons in the course of their work as counsellors. They reveal such information to others only with the consent of the person or person’s legal representative, or in unusual circumstances in which not to do so would result in clear danger to the person or to others. Where appropriate, counsellors inform their clients of the legal limits of confidentiality, which are: The therapist may be required to give evidence if subpoenaed by a court of law; The therapist may report concern to appropriate persons if there is reason to believe that as a result of a client's actions the life or well-being of any person might be endangered; The therapist will inform the Ministry of Child and Family Development if there is suspicion that a client is responsible for a child being abandoned, deserted or maltreated. *

Change for Good.