Contact ​Colleen Pelletier

    CHILD & TEEN THERAPY INTAKE FORM

    This online form is intended for Children and Teens.
    About you
    Other parent/legal guardian
    About the child/teen
    Medical history
    Symptoms List
    *Parents, if possible, please allow your child to complete this portion. If your child is too young, complete symptom check list from your observations of your child. 
    AGREEMENT FOR PARENTS OF MINOR CHILDREN
    Counselling can be a very important resource for children. Establishing a therapeutic alliance outside of the home can:​
    • Facilitate open and appropriate expression of strong feelings such as guilt, grief, sadness and anger.
    • Provide an emotionally neutral setting in which children can explore these feelings.
    • Help children understand, accept, and cope with whatever difficulty they may be experiencing.
    ​• Offer feedback and recommendations to a child’s caregivers based on knowledge of the child’s specific emotional needs and developmental capacities.

    However, the usefulness of therapy may be limited when the therapy itself becomes simply another matter of dispute between parent and child or between parents. With this in mind, and in order to best help your child, I strongly recommend that your child and each of the child’s caregivers (e.g., parents or stepparents) mutually accept the following as requisites to participation in therapy.

    1. As your child’s counsellor, it is my primary responsibility to respond to your child’s emotional needs. This includes, but is not limited to, contact with your child and each of his or her caregivers, and gathering information relevant to understanding your child’s welfare and circumstances as perceived by important others (e.g., paediatrician, teachers). In some cases, this may include a recommendation that you consult with a physician, should matters of your child’s physical health be relevant to this therapy.
    2. I ask that all caregivers remain in frequent communication regarding this child’s welfare and emotional well-being. Open communication about his or her emotional state and behavior is critical. In this regard, I invite each of you to initiate frequent and open exchange with me as your child’s therapist.
    ​3. I ask that caregivers recognize and, as necessary, reaffirm to the child, that I am the child’s helper. This may include encouragement for the child that is reluctant or anxious about therapy, or support and optimism regarding change. Also, I have found that use of therapy as a consequence or punishment is usually not helpful.
    4. This counselling Will Not yield recommendations about custody, nor do I provide reports
    The Client/Parent agrees:
    1. To provide prior notice of 24 hours if canceling an appointment. (Voicemail can be left anytime) Failure to provide proper notice may result in a personal charge for the late cancellation. Your prompt cancellation will permit someone else to the time and thus reduce the waiting periods for others;

    2. To pay the Therapist’s fees at end of each session. If you are using an Employee Assistance Plan or Insurance Policy, you are responsible for paying the full fee and submitting your claim personally. It is the Client’s responsibility to ensure your Therapist meets the criteria for your specific Employee Assistance Plan or Insurance Policy. Neither the therapist nor The Counselling Corner is responsible for denied claims.

    3. If you subpoena your therapist or anyone from The Counselling Corner, costs for court preparation, client rescheduling and court appearance(s) will be paid by the client/parent at a rate of $180 per hour.

    The Therapist agrees:

    1. To provide counselling assistance based upon the Client’s/Parent's goals.

    2. To maintain the confidentiality of the Client, unless:

    a) He/she may be a danger to yourself or others, or there is a reasonable suspicion of child abuse or neglect. You recognize in such circumstances that I have a legal and ethical responsibility to my professional association to notify the proper authorities.

    b) It is appropriate to consult with a professional colleague to improve the quality of my service to you ; the information shared with this professional colleague will be kept anonymous and is restricted to the information necessary to aide in meeting your desired goals and to assist me in providing adequate service. This colleague will also be held to the rules of confidentiality.

    ​c) You initiate a legal action whereupon I may use information from my records to defend myself.
    [INSERT THERAPIST'S NAME HERE] has agreed to their duties as the "Therapist", identified in the paragraphs above.

    by clicking "submit" the client agrees to share the information entered throughout this form with Colleen Pelletier.

    ​signatures will be gathered upon the initial appointment.