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Intake Adult Guardianship Third Party

We appreciate your role in supporting the individual seeking therapy. As their guardian, completing this intake form is an essential step in ensuring they receive the best possible care. Your input will help us create a supportive and personalized experience tailored to their needs.

Your privacy and confidentiality are important to us. The information you provide will be used solely to support the therapeutic process. Please take your time completing the form, and if you have any questions or need assistance, don’t hesitate to reach out—we are here to help.

Important Information:

  • As the legal guardian, your signature is required in two places within the form. You can sign easily from a mobile device, tablet, or computer.
  • The form must be completed in one sitting, as responses do not save. It should take approximately 10 minutes to complete.
  • Click Submit once you have finished.
  • If you have any questions or encounter any issues, please contact our office for assistance.

Thank you for your time and for supporting this process.

 

Personal Information

Client's Full Name
Date of Birth
Please provide the names and contact information the Guardians and / or legal decision makers in respect to the individual receive services. 
Legal Guardian [Primary Contact]
This is for scheduling, communication and where receipts will be issued.
Is there a Guardianship Order in place?
Client Primary Address

History and Personal Information

Please complete all fields, put N/A if not applicable.
Consent For:
Please select one
Indicate name, dose and purpose
Provide Name and Phone Number
How would you rate the person's physical health?
Are there any concerns regarding substance use?

CONSENT 

Nature of Counselling:

The therapists at Your Counselling Ltd. approach child and youth counselling from an integrative perspective, drawing on techniques such as Client-Centered, Cognitive-Behavioural, Narrative Therapy, Dialectical Behavioral Therapy (DBT), and Solution-Focused strategies. Each approach is tailored to the child or youth’s unique needs and circumstances, ensuring they feel heard and supported throughout the process.It’s important to encourage young clients and their guardians to ask questions about the therapist's training and credentials during the initial session. Therapist profiles and educational backgrounds can also be reviewed at: Your Counselling - Meet Our Team.

Counselling Services for Children/Youth:

Counselling for children and youth is a highly personalized and evolving process, shaped by the interaction between the young client and therapist, as well as the specific issues being addressed. While counselling can lead to positive outcomes such as better emotional regulation, improved coping strategies, enhanced self-esteem, and improved relationships with family and peers, it can also bring up uncomfortable emotions like sadness, anger, or frustration. These feelings are a natural part of the healing and self-discovery process.

Therapy sessions are an opportunity for young clients to reflect on their thoughts and feelings, gaining insights that can lead to positive changes in behaviour and emotional well-being. The initial sessions often involve getting to know the young client, assessing their needs, and developing a treatment plan if therapy is to continue. Throughout this process, the youth’s comfort and engagement with the therapist are key.

Confidentiality:

Confidentiality is a fundamental right for children and youth in therapy, and information shared during sessions remains private unless the client provides written consent for its release. However, there are specific exceptions to confidentiality in child/youth therapy:
(a) Duty to Warn: If a young client is at risk of harming themselves or others, or if there is suspected or confirmed abuse involving the client or another vulnerable person, the therapist is legally obligated to report this to the appropriate authorities.
(b) Court Subpoenas: Legal cases may require the disclosure of a counsellor's notes or records.
(c) Consultation: The therapist may confidentially discuss the child’s case with other professionals to ensure the best possible care, without revealing identifying information.

Rights of Young Clients:

Young clients and their guardians have the right to ask questions about any part of the counselling process. The therapist is always open to discussing different methods and approaches, ensuring the child’s comfort. Additionally, young clients have the right to refuse certain counselling techniques if they do not feel at ease, and guardians can request referrals if they believe another therapist might be a better fit.

Record Keeping:

All records, including demographic and clinical documentation, are maintained in a secure digital format utilizing encryption protocols and industry-standard safeguards to prevent unauthorized access, use, or disclosure. Such records shall be retained for a minimum period of seven (7) years following the date of the final termination session, in accordance with applicable professional, legal, and regulatory requirements.

Clinical records are concise in nature, documenting attendance, therapeutic interventions, and general discussion topics relevant to the course of treatment. Individual session notes may not be disclosed. Upon written request, clinical summaries may be prepared and made available to the client or other authorized parties, subject to applicable legislation and professional standards governing confidentiality, disclosure, and record-keeping.

The treating therapist shall ensure appropriate document control, confidentiality, and compliance with all relevant professional obligations and statutory requirements. Reasonable administrative fees may apply for the preparation, duplication, or transmission of such summaries.

Contacting the Therapist:

Therapists may not always be available immediately by phone. Voicemails are typically answered within 36 hours, and emails are generally responded to within the same timeframe. If the therapist is unavailable for an extended period, an alternate contact will be provided. The administrative team is available Monday through Friday to assist with scheduling.

Emergencies:

In the case of an emergency between sessions, young clients and their guardians are encouraged to contact Distress Centre Calgary (403-266-4357), visit the nearest Emergency Room, or call 911.

Clinic Structure:

The therapists working under the name “Your Counselling Ltd” are independent practitioners. While they may collaborate on business and clinical matters when necessary, each therapist is autonomous and handles their own client concerns. Should there be a need, young clients and their guardians can request the contact information for the therapist’s governing body based on their registration.

Clear Signature
Upon signing, you are indicating that you have read and understood this consent form. You agree to accept the counselling services as detailed above. By signing you are indicating you have the legal authority to consent on behalf of the person noted above.

Fee Schedule 

Effective July 18, 2023 

Standard Rates:

Individual Adult (18+) Counselling $160.00 to $180.00 per 50 min session.

(Rates for each Therapist are posted here.)

Youth (13 and Over) Counselling $160.00 to $180.00 per 50 min session.

(Rates for each Therapist are posted here.)

Child (12 and Under) Counselling $200.00 per 50 min session.
Family Counselling $200.00 per 50 min session; or

$300.00 for a 90 min session

Couples Counselling $200.00 per 50 min session; or

$300.00 for a 90 min session

Accelerated Resolution Therapy (ART) or EMDR $250.00 per 75 min session; or

$300.00 for a 90 min session

Start the Conversation Program Fees as detailed in Statement of Understanding.
Document/Letter Writing $160.00 per hour

* Fees are billed in 15 min increments based on session type should any variation need to occur. In these instances, for extended or shortened Sessions, fees will be discussed with your therapist.

Fees are paid following each session. Debit, Credit, Cash, and E-Transfer are all accepted forms of payment. Detailed receipts are provided following payment.

While we offer direct billing to various insurance companies we cannot speak to the level/type of coverage you have as we are not able to access this information.

Any balance not covered by direct billing is payable at the end of your session.   

CANCELLATION AND MISSED APPOINTMENT POLICY

We consider any appointment that you have made important. Your appointment is for your exclusive use and when it is cancelled with short notice, or missed altogether, it is too late or impossible to offer this time to someone else and the appointment time goes unfilled.

The following outlines how missed and late cancelled appointments are handled:

  • A full 24-hour notice period is required for cancelling appointments.
  • Confirmation from either our booking system or our admin team is required for confirm a session has been successfully cancelled.
  • If you cancel with less than 24 hours before your appointment time, you will be billed for 100% of the cost of your appointment.
  • Clients who fail to show up for a scheduled appointment (“no show”) are billed/invoiced for the full cost of their scheduled session.
  • Our booking system will send out reminder emails. These reminders are a courtesy only; clients are responsible to keep or cancel their appointment regardless of whether they receive a reminder or not.
  • If you are uncertain when your next appointment is, please call our office.
  • There is a range of valid reasons for cancelling an appointment. To be consistent with all clients, cancellation fees will only be waived in the event of a documented medical emergency requiring urgent professional treatment, a death in the family or unsafe weather for travelling (i.e. severe snowstorm).
  • If you have booked a series of counselling appointments and have cancelled your most recent appointment with less than 24 hours’ notice or have missed that appointment, you have 24 hours to pay the associated fees to retain your remaining pre-booked sessions.
  • For any bookings of more than two (2) appointments in the future, we require a credit card on file. This  helps us manage our schedule effectively and ensures your appointments are confirmed. Your card will only be charged in accordance with this cancellation policy.
  • Missed appointments and late cancellations are payable via debit, credit, cash or e-transfer prior to your next session.
  • All no-show fees or cancellations fees collected have receipts marked “cancellation fee” or “missed appointment” and cannot be marked as a “counselling session”.
  • We are unable to direct bill your insurance for any late cancellation or no show appointments.
  • Weekend Appointments must be cancelled by the Friday before the appointment occurs.
  • Clients with overdue invoices and funds owned are not able to book sessions.
  • Any unpaid accounts may be referred to a third-party collection agency for recovery. To avoid this, we encourage timely payment or to contact us to discuss payment arrangements.
  • Online scheduling may, at times, be unavailable at our discretion or due to automatic system changes. This may occur as a result of program requirements, outstanding invoices, or a pattern of frequent cancellations, changes, or no-shows. When online booking is unavailable, appointments must be scheduled through our reception team during regular business hours.

For support with scheduling, please call our reception team during our regular business hours.

Clear Signature
By signing above, you are indicating that you have read and understood the fee agreement.