Intake Consent In Person

** Client Information Form **

Part A - Your Contact Information
=======================

1. First and Last Name.

2. Date of Birth.

3. Address.

4. City, Province.

5. Postal Code.

6. Home Phone.

7. Cell or Work Number.

8. Email.

Part B - Information About You and Your System
========================================

9. Gender Identification. —Please choose an option—FemaleMaleTransgenderPrefer not to say

10. Relationship Status. —Please choose an option—MarriedCommon LawDatingLookingSingleSeparatedDivorcedWidowed

11. Number of Dependents.

12. Number of Children.

13. Reasons for Counseling. Pick as many as applies. —Please choose an option—RelationshipStressDepressionAnxietyGrief-DeathHealthJob-WorkFinancialSexParentingHealthConflict-AngerChildrenSubstance Use

14. Goals for counseling:

Part C - Referral Information
=======================

How did you find out about us: —Please choose an option—DoctorMinister-ChurchSocial AgencyLawyerDrop-in CenterHospitalPrivate CounsellorEmployee AssistanceClient/FriendLiving Systems websiteOther websiteOther

Have you used Living Systems before: YesNo

Please enter your counselor's email here.
(NOTE: PLEASE DOUBLE-CHECK YOUR ENTRY FOR THIS EMAIL ADDRESS TO ENSURE IT IS CORRECT.)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

** Client Consent (IR) Form **

1. Your Counsellor: My Counselor's name is: My counsellor's supervisor is:

(NOTE: If your counsellor currently attends the training program and is receiving regular supervision please enter the supervisor's name.)

2. Therapeutic Orientation and Counselling outcomes: Living Systems Counsellors use a Bowen Family Systems Theoretical orientation (BFST). We believe BFST can help people to think more clearly about themselves and their relationships. Each person and family responds to counselling differently. Your counsellor will speak to you about some of the things you may expect from counselling. For more information on BFST see www.livingsystems.ca

3. Quality of counselling: I understand that Living Systems places a high value on the quality of counselling and professional competence among our counsellors. If you at any time would like to speak to someone about the quality of care whether you are extremely satisfied or have had some difficulty or complaint, please contact Ms. Katherine White 604-926-5496. Additionally, if your counsellor is registered you have the right to contact their professional organization.

4. Emergency: I understand that Living Systems is not a crisis counselling organization and does not have 24-hour counsellor access. If you have an emergency please dial 911, if you have an urgent need please call the crisis phone line at 604-872-3311. If you leave a message for your counsellor, they will return your call within 24 hours or the next business day.

5. Fee: I understand my per-session fee is - - and is payable at each session. Living Systems accepts cash and cheque. There will be a $10 bank fee for a returned cheque.

6. Cancellation Policy: I understand that I will be responsible for paying the full fee of any missed sessions when 24 hours notice has not been given.

7. Audio or videotaping: I give permission for our sessions to be video or audio taped for the sole purpose of individual supervision and/or group supervision and consultation. Indicate N/A if you would like to waive.

8. Referral: I understand that if I was referred by a professional, that person may be notified and thanked for the referral unless I ask this not to be done.

9. Confidentiality:
-- I understand that all communications between me and my intern or counsellor(s) are confidential and that the therapist(s) will not disclose to anyone beyond the therapist's professional colleagues at Living Systems andy information disclosed in the sessions.
-- There are unique confidentiality concerns in sessions where there are multiple participants. Your counsellor will address these with you if more than one person participates in the counselling.
-- I understand there are exceptions to legal confidentiality and professional ethics. Such exceptions include but are not limited to: files subpoenaed by a court of law, disclosure or suspicion of child abuse or neglect; perceived threats of suicide, homicide, and risk of injury to self or others.
-- Other limits to confidentiality can include if you, as an employee, appear to pose a threat of serious injury to themselves or others in a safety-sensitive occupation (e.g. an employee who may be impaired when operating heavy machinery); the therapist is told by the client that a regulated health professional, such as a social worker, psychologist, physician or surgeon, dentist, etc. has behaved in a sexually inappropriate manner with the client.
-- Another element of confidentiality is that your counsellor will not accept any social media requests from you, nor will your counsellor search you on a search engine (such as Google) or social media.

10. Our privacy obligation to you:
-- In accordance with the Personal Information Protection Act (PIPA), your privacy is protected and your written authorization is required to release personal information except for reasons outlined above as exceptions to confidentiality.
-- Only authorized individuals within Living Systems may access your personal information. Personal information is any recorded information that identifies you. At Living Systems, your personal information will be used by your counsellor to assist in your work with them and general information that does not identify you as a person may be used for grant application purposes.
-- Your clinical record is stored under lock and key for the duration of your time receiving services with Living Systems. Following the end of services, the record is kept for 7 years in a secured storage facility (If a minor is seen, records are kept 7 years past the age of majority).
-- You can request access to or copies of your health record by writing to Living Systems. We may require up to 30 days to process the request. We charge a fee to cover the basic costs of the request.

11. Contact: I give my consent for my counsellor to contact me by email and/or text to arrange appointments or receive communication. I understand that this communication is not secure and my counsellor will speak to me about how they use these forms of communication.

12. Emergency contact: If my therapist is unable to contact me, I give permission to contact:

Emergency contact's name:

Emergency contact's email address:

Emergency contact's phone number:

Emergency contact's relationship to you:

I have read and I understand the above form and consent to counselling with Living Systems:

Client Signature (1):

Client Signature (2):

My Email Address:
Date:

Counsellor's Signature:

Your Counsellor's email address:
(NOTE: PLEASE DOUBLE-CHECK YOUR ENTRY FOR THIS EMAIL ADDRESS TO ENSURE IT IS CORRECT.)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

** INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS **
 
This document contains important information about our decision (yours and mine) to resume in-person services in light of the public health crisis. Please read this carefully and let me know if you have any questions.  When you sign this document, it will be an agreement between us.

The decision to Meet Face to Face
We've agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we meet via telehealth. If you have concerns about going back to telehealth, we'll talk about it first and try to address the issue. You understand that, if I believe it is necessary, I may determine that we return to telehealth for everyone's well-being. If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is clinically appropriate. 
 
The Risks of Opting for In-Person Services
You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service.
 
Your Responsibility to Minimize Your Exposure
To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, and others) safer from exposure, sickness, and possible death. Your failure or refusal to adhere to these safeguards may result in our starting / returning to a telehealth arrangement.  

Please initial each to indicate that you understand and agree to these actions:

You will only keep your in-person appointment if you are symptom free.

You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more, or 38 Celsius or more), or if you have other symptoms of the coronavirus (For example, a runny noise, sore throat, loss of appetite, loss of taste), you agree to cancel the appointment or proceed using telehealth. If you wish to cancel for this reason, I won't charge you our normal cancellation fee.

You will wait in your car or outside until no earlier than 5 minutes before our appointment time.

You will wash your hands or use hand sanitizer when you enter the building.

You will adhere to the safe distancing precautions we have set up in the waiting room and therapy room. For example, you won't move chairs or sit where we have signs asking you not to sit.

You will wear a mask in all areas of the office (I will too). You will be responsible for providing this mask. If you need to purchase a mask from Living Systems you may discuss this with your counsellor.

You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with me.

You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands.

Children will not be permitted to attend sessions unless prior approval from counsellor has been granted.

You will take steps between appointments to minimize your exposure.

If you have a job that exposes you to those who are infected, you will let me know.

If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me know.
If a resident of your home tests positive for the infection, you will immediately let me know and we will then begin or resume treatment via telehealth.
 
I may change the above precautions if additional local, provincial or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

** Living System’s Commitment to Minimize Exposure **

Living Systems has taken steps to reduce the risk of spreading the virus within the office and we have posted our efforts on our website and in the office. Please let me know if you have questions about these efforts. 

If You or I Are Sick

You understand that I am committed to keeping you, me, and all of our families safe from the spread of this virus. If you show up for an appointment and I believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately.  We can follow up with services by telehealth as appropriate.
If I, or a family member, test positive for the coronavirus, I will notify you so that you can take appropriate precautions.

Your Confidentiality in the Case of Infection

If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details of the reason(s) for our visits.  By signing this form, you are agreeing that I may do so without an additional signed release. 

Informed Consent
This agreement supplements the general informed consent agreement that we agreed to at the start of our work together. 

** Filling in your full name and email below shows that you agree to these terms and conditions. **
 
Safety Precautions in Effect During Pandemic
 
Living Systems is taking the following precautions to protect our patients and help slow the spread of the coronavirus.
 
Office seating in the waiting room and in therapy/testing rooms has been arranged for appropriate physical distancing.
- I will wear masks.
- I will maintain safe distancing.
- Common areas are thoroughly disinfected at the end of each day.
- Restroom soap dispensers are maintained and everyone is encouraged to wash their hands.
- Hand sanitizers that contain at least 60% alcohol are available in the therapy/testing rooms, the waiting room and at the reception counter.
- We schedule appointments at intervals to minimize the number of people in the waiting room.
- We ask all patients to wait in their cars or outside until no earlier than 5 minutes before their appointment times.

- We are not accepting cash or check during this time and only accept e-transfers
- Physical contact is not permitted.
- We are asking clients to bring their own tissues and leave with them after the session.

 
Your Signature (type in your name in lieu of signature):

Your email address:

Date:

My Counselor's email address is:

(NOTE: PLEASE DOUBLE-CHECK YOUR ENTRY FOR THIS EMAIL ADDRESS TO ENSURE IT IS CORRECT.)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.