Child Counselling Intake & Consent

To be completed by the legal guardian(s) of an individual 17 years and under who is attending a counselling session.

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We are pleased that you’ve chosen to embark on this journey with us to support the well-being of your child or youth. Completing this intake form is the first step toward ensuring that we provide a personalized and compassionate experience tailored to their unique needs.

At Your Counselling, we understand that each child is different, and their mental health and emotional well-being are important to their growth. The information you provide will help us gain a deeper understanding of your child’s situation and how we can best support them through their challenges. Rest assured, everything shared is kept confidential, and we encourage you to take your time with the form.

If you have any questions or need assistance during the process, please don’t hesitate to reach out to us. We’re here to support both you and your child every step of the way.

Please note the following:

  • The Legal Guardian of the child / youth is to complete this package
  • All contact information should be in reference to the Legal Guardian
  • There are two places where a signature is required, which you can do easily from any mobile device, tablet or computer.
  • Fields do not save as you go and the form must be completed in one sitting. It will take about 5-10 mins to complete
  • Click Submit when done.

If you have any issues or questions about this form please contact our office.

Personal Information

Child's Full Name
Name of Signer
Date of Birth

Please provide the full names and contact information for all parents, guardians, and/or legal decision-makers with respect to the child or youth.

Is there a parenting order in place?
Legal Guardian / Parent [Primary Contact]
This is for scheduling, communication and where receipts will be issued.
Address

History and Personal Information

Please complete all fields, put N/A if not applicable.
Request for:
Indicate name, dose and purpose
How would you rate the child's physical health?
Are there any concerns regarding substance use?
This form will be reviewed during the intake session and kept on file with your therapist. You may request a copy at any time. Would you like to receive a copy of this form once it has been completed?
If there is a secondary contact, both intake forms create the intake package. This will be combined for the client’s file, this may be reviewed or requested by either signer.

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.

Respectful Communication and Conduct:

Your Counselling Ltd. is committed to providing a safe, respectful, and professional environment for clients, therapists, administrative staff, and visitors.

We recognize that counselling often occurs during times of significant stress, frustration, or emotional difficulty. Clients are encouraged to share concerns, ask questions, and provide feedback about their care or experience with the practice. We are committed to addressing concerns in a respectful and professional manner.

To support a safe environment for everyone, abusive, threatening, harassing, intimidating, discriminatory, or aggressive communication and behaviour will not be tolerated. This includes conduct that compromises the safety, dignity, or well-being of our team, clients, contractors or others connected to the practice.

This expectation applies to all forms of interaction with the practice, including in-person, by telephone, email, text message, video session, social media, or any other form of communication.

If respectful communication or conduct is not maintained, the practice may take appropriate steps to support safety and professional boundaries. This may include pausing communication, limiting written correspondence, cancelling or rescheduling future appointments, restricting communication to written correspondence, suspending or terminating services immediately, and/or referring the client to alternative service providers where appropriate. Any outstanding fees remain payable in accordance with this agreement.

By engaging in services with our practice, you acknowledge and agree to maintain respectful communication and conduct throughout your relationship with the practice.

Adherence to Parenting Orders

At Your Counselling Ltd., we are committed to upholding any existing legal parenting agreements or court orders. As part of this commitment, all communication, information sharing, and involvement in a child’s care will be carried out in accordance with the terms outlined in the current parenting order(s) provided to us. It is the responsibility of the parent(s)/guardian(s) to inform us of any changes to these orders and to provide supporting documentation as necessary.

Unless otherwise specified by a valid court order, all communication regarding a child’s care—including scheduling, updates, and documentation—will be shared equally with both parents/guardians. Your Counselling Ltd. does not act as an intermediary between guardians and expects parents to communicate directly with each other regarding matters related to their child’s care, unless legally restricted.

Failure to disclose relevant legal information or meet the communication expectations outlined above may impact our ability to provide appropriate and compliant care.

Record Keeping

Your Counselling Ltd. maintains your demographic and administrative record, including information such as your contact details, appointment history, billing information, consent forms, and other non-clinical documentation. Your treating therapist maintains your clinical record, including documentation related to your assessment, treatment, and therapeutic progress.

All records are maintained in a secure digital format utilizing encryption protocols and industry-standard safeguards designed to prevent unauthorized access, use, or disclosure. Records are retained for a minimum of seven (7) years following your final session, or longer where required by applicable legislation, regulatory standards, or professional obligations.

Clinical records are concise in nature and document attendance, clinical observations, therapeutic interventions, treatment planning, and general topics relevant to the course of therapy. Process notes or personal working notes maintained by a therapist, where applicable, are not considered part of the clinical record and are generally not subject to disclosure.

Upon written request, your therapist may prepare a clinical summary for you or another authorized party, subject to applicable privacy legislation, professional standards, and your written consent where required. Individual psychotherapy session notes are not routinely released. Reasonable administrative fees may apply for the preparation, duplication, or transmission of records or summaries.

Your treating therapist is responsible for the creation, maintenance, security, and professional management of the clinical record in accordance with the standards of their regulatory college and all applicable legal and ethical requirements.

Contacting your Therapist:

For scheduling, billing, or other administrative matters, please contact our main office. Our administrative team is available Monday through Friday and will be happy to assist you.

Therapists are not available by telephone without a pre-arranged appointment.

If you leave a voicemail or send an email directly to your therapist, messages are typically reviewed and responded to within 36 hours during regular business days.

If your therapist will be away for an extended period, you will be provided with an alternate contact for time-sensitive matters. For urgent scheduling or administrative concerns, please contact our administrative team through the main office.

Emergencies:

In case of an emergency between sessions, clients are advised to contact the appropriate support based on their location:

  • Calgary: Contact the Distress Centre Calgary at 403-266-4357 (available 24/7), visit the nearest Emergency Room or Urgent Care Centre, or call 911 for immediate assistance.
  • Dartmouth and surrounding areas: Contact the Mental Health Crisis Line at 1-888-429-8167 (available 24/7), visit the nearest Emergency Room, or call 911 in an emergency.

Clients in either location may also call the 988 Suicide Crisis Helpline, a national, 24/7, confidential service available across Canada, by dialing 988.

Clinic Structure:

Therapists operating under the name “Your Counselling Ltd” are independent practitioners and not business partners. While they may collaborate on clinical or business matters when necessary, each practitioner is autonomous. All client concerns are addressed directly between the client and their respective therapist.

Questions, Concerns, and Feedback

We are committed to providing a respectful, responsive, and professional experience.

If you have questions, concerns, or feedback about your therapeutic care or your therapist’s clinical services, we encourage you to discuss these directly with your therapist whenever possible. Many concerns can be resolved through open communication within the therapeutic relationship.

For administrative matters—including scheduling, billing, clinic policies, documentation requests, or other non-clinical concerns—please contact our Client Services Team. They are responsible for the administration of the practice and are authorized to make decisions regarding administrative policies and procedures. Decisions made by the Client Services Team on administrative matters are considered final.

If your concern relates to a therapist’s professional conduct, ethics, or standards of practice, our Client Services Team can provide you with the contact information for your therapist’s regulatory college and explain the appropriate complaint process.

Professional Consultation and Collaboration

To support the highest quality of care, your therapist may consult with other therapists or members of the clinical leadership team within the practice regarding your care. These consultations are intended to enhance clinical decision-making, treatment planning, and professional support.

Whenever possible, these discussions are conducted using non-identifying information. All individuals involved are bound by the same legal, ethical, and professional obligations of confidentiality. Information is shared only to the extent necessary for clinical consultation and in accordance with applicable privacy legislation and professional standards.

By providing your consent to treatment, you acknowledge and consent to these professional consultations as part of the delivery of your care.

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 child/youth noted above.

Fee Schedule 

Effective July 18, 2025

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.