We are thrilled that you’ve chosen to begin your group therapy journey with us. Completing this intake form is an important first step in creating a supportive and meaningful experience tailored to your needs. In group therapy, your comfort and well-being are our highest priorities, and the information you provide will help us understand your unique circumstances and how to best support you in a group setting. Rest assured, everything shared here is confidential, and we encourage you to take your time as you fill out the form. If you have any questions or need assistance at any point, please reach out—we’re here to support you at every step.

Please note the following:

  • There are two places requiring a signature, which you can complete on any mobile device, tablet, or computer.
  • The form does not save, so it must be completed in one sitting. It should take about 10 minutes.
  • Click “Submit” when done.

If you encounter any issues or have questions, please contact our office.

Personal Information

Full Name
Preferred Contact Method
Address

History and Personal Information

Please complete all fields, put N/A if not applicable.
Request For:
Indicate name, dose and purpose
Marital Status
What is your current occupation and educational history?
Are you involved in any custody, access dispute, disagreement or any legal difficulties

                                      CONSENT

We encourage you to ask questions regarding your Therapist’s education, training and credentials prior to your first session. You can also review their profiles and education by going to: https://yourcounselling.ca/get-to-know-us/


Group Therapy Services

Group therapy is a collaborative, shared experience that encourages personal growth through connection with others who face similar challenges. Success in group therapy depends on the active participation and openness of all members, who are both supported by and supportive of each other. Group counselling offers many benefits, such as improved coping strategies, skill-building, reduced distress, enhanced self-esteem, and stronger social connections. However, group therapy can also bring forth complex emotions, such as vulnerability or frustration. Initial sessions are used to assess individual and group needs, and members are encouraged to gauge their comfort with the group setting, as therapy requires a substantial investment of time, energy, and emotional openness.

Confidentiality in Group Therapy

Confidentiality is essential to a safe and trusting group environment. All discussions within the group are strictly confidential, and members are asked to respect the privacy of others by not sharing group content outside of sessions. Information will only be disclosed without written consent in specific cases, including: (a) Duty to Warn, if there is a danger to any individual or in cases of suspected abuse of a child, elder, or vulnerable person; (b) Court Subpoenas, if legal processes require disclosure of group records; and (c) Consultation, where information may be reviewed confidentially with other professionals to enhance group care, with members’ identities protected.

Rules for Participants

To maintain a positive and constructive group experience, all members are expected to adhere to the following rules:

  1. Confidentiality: Respect the privacy of fellow group members by not discussing any identifying details or personal information outside of the group.
  2. Respect: Engage in respectful, non-judgmental listening and speaking. Refrain from interrupting, giving unsolicited advice, or engaging in confrontational behavior.
  3. Punctuality and Consistency: Arrive on time and attend all scheduled sessions. Consistent attendance supports group cohesion and builds trust.
  4. Participation: Actively participate in discussions and activities, to the extent of your comfort level. Open sharing enhances both individual and group growth.
  5. Boundaries: Respect personal boundaries, including refraining from physical contact or discussing sensitive issues if someone is uncomfortable.
  6. Feedback: Offer constructive feedback, when appropriate, and be open to receiving feedback from both the therapist and group members in a supportive manner.
  7. Focus on the Present: Keep discussions focused on current experiences, thoughts, and feelings, as this encourages meaningful, relevant connections within the group.
  8. For virtual group sessions, please join from a confidential and private space. Ensure cameras are on throughout the session to support group confidentiality, and please refrain from recording or taking photos of any participants

Breaking these rules can impact the group’s progress and may lead to a discussion with the therapist about continuing participation.

Members’ Rights in Group Therapy

Group members have the right to ask questions about any aspect of the group process, and therapists are open to discussing their methods. Members may request adjustments or opt out of specific activities if they feel uncomfortable. Members may also inquire about the therapist’s qualifications and discuss the option of individual therapy if group therapy feels unsuitable. Participants are free to discontinue group therapy at any time, though a termination session is recommended to provide closure.

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.

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.

Fee Schedule 

Effective July 18, 2023 

Standard Rates/Fees for Group Therapy

Current Group Offerings: 

ANGER:  $50.00 ( for 2 modules )

ADHD: $50.00 ( for 2 modules )

GRIEF & HEALING: $300.00 ( for 4 modules )

RADICAL SELF COMPASSION: $300.00 ( for 2 modules )

A hold payment is due at the time of registration. This will go towards the first group session and will hold your spot in Group. After this there are two options for payment:

Option A: The full amount remaining can be paid at once.

Option B:  Payment can be made after each session.

Participants are expected to attend all sessions to gain the full benefits of the program. If you are unable to attend a session, the fee remains unchanged, no refunds will be made for missed sessions. By signing this form you are committing to the total cost of the series

While we offer direct billing to various insurance companies, we cannot confirm your level or type of coverage since we do not have access to this information. Any balance not covered by direct billing is due at the end of the session.

Cancellation and Missed Appointment Policy for Group Therapy

Group therapy sessions are valuable for both the individual and the group as a whole. When one participant cancels on short notice or misses a session, it can impact the group dynamic and make it difficult to maintain continuity. The following outlines how missed and late-cancelled appointments are handled:

  • Cancellations made within 5 days of the starting date/time are subject to the full group fee.
  • Cancellations must be confirmed by either our booking system or admin team to ensure the session is successfully canceled.
  • Clients who do not show up for a scheduled session (“no show”) are responsible for the full cost of that session.
  • Our booking system will send reminder emails as a courtesy; however, clients are responsible for keeping or canceling appointments regardless of receiving a reminder.

Exceptions to the Cancellation Policy

Missed appointments and late cancellations are payable via debit, credit, cash, or e-transfer before the next session. Receipts for these charges are labeled as “cancellation fee” or “missed appointment” and cannot be marked as a “counselling session.” We cannot direct bill insurance for missed or late-cancelled appointments.

Clients with overdue invoices cannot book further sessions ( regardless of the type)  until their accounts are settled.

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