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Contact <Counsellor name>

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Name *

First

Last

Email *

Message *

*Please do not send confidential information. Information that is exchanged between potential clients and counsellors are not protected until the necessary agreements are signed.

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Adult intake form

This form is intended for potential people who are 18 and older.

CLIENT INFORMATION to be completed by all new and any former clients who have not been seen for 12 months or more.

* Indicates required field

Primary Client(s) Full Name *

First

Last

Street Address *

City/Town *

Postal Code *

Cell Phone/Main Phone *

Home Phone *

Work Phone *

Other Phone *

Preferred method of contact *

Call Text

Age *

Date of Birth (MM/DD/YYYY) *

Gender *

Occupation *

Years of service *

Relationship status *

Emergency contact

Emergency Contact's Name *

First

Last

Emergency Contact's Phone Number *

Family Information: (Who you are residing with at this time. Ex. Mother, Father, Spouse, or Children).

Mother's Name *

First

Last

Mother's Age *

Spouse's Name *

First

Last

Spouse's Age *

Father's Name *

First

Last

Father's Age *

Children's Name(s) *

First

Last

Children's Name(s) *

Significant others *

Such as brothers, sisters, grandparents, step-relatives, half-relatives, please specify relationship.

Please answer only the questions that apply, or that you are comfortable answering. The facts of this form will be held in the strictest confidence. If you are filling this form out on behalf of someone else, answers should be from the client’s perspective.

Personal History *

Briefly describe what brought you here today. Some examples might be: anger management, anxiety, depression, eating disorder, fear/phobias, loss or grief, self-esteem, suicide, self-injury, bullying, abuse, addictions, separation/divorce, parenting.

Approximately, how long have you had this concern *

What are your goals for counselling? *

Are there special, unusual, or traumatic circumstances that have affected your life? *

What strengths and qualities do you admire about yourself? *

Has there been a history of child abuse? *

Yes No

If yes, which type(s)? *

Sexual Physical Verbal

Medical/Physical Health

Please list any current health concerns: *

Medication(s) and Reason for Medication(s)? *

Physician’s Name: *

First

Last

Family history of medical problems *

Chemical Use History

Are you currently using any alcohol or drugs? *

No Yes

If yes, what are you using and how long have you been using? *

Describe any changes in your use patterns: *

Describe when and where you typically use substances: *

Describe how your use has affected your family or friends: *

include their perceptions of your use.

Reason(s) for substance use: *

Addiction Builds Confidence Escape Self-medication Social activity Taste

Check any boxes that you feel apply.

If a reason is not listed, please list it below *

Who or what has helped you in stopping or limiting your use? *

How do you believe your substance use affects your life? *

Does/Has someone in your family present/past have/had a problem with drugs or alcohol? *

No Yes

If yes, please specify who and why someone has/had a problem with drugs/alcohol *

Have drugs or alcohol created a problem for your job/personal life? *

No Yes

if yes, specify how have drugs/alcohol created a problem for your job/personal life? *

Counselling/Prior Treatment History

Are you seeing another counsellor at this time? *

No Yes

Current or Prior Psychiatric treatment? *

No Yes

If yes, please describe the psychiatric treatment *

Do you feel suicidal at this time? *

No Yes

if you are suicidal at this time please elaborate *

Hospitalizations? *

No Yes

if yes, please describe the hospitalization *

Have you had counselling prior to today? *

No Yes

if yes, please describe the counselling *

Suicidal thoughts/attempts? *

No Yes

If Yes, please describe the suicidal thoughts/attempts *

Drug/alcohol treatment? *

No Yes

if yes, describe the drug/alcohol treatment *

Involvements with self-help groups? *

No Yes

Such as AA, Al-Anon, NA, etc

If yes, please elaborate on your involvements with any self-help group(s) *

Any additional information that would assist in understanding your concerns or problems? *

Finally, Who/what referred you to The Counselling Corner? *

Relative Friend Website Facebook Kijiji Phone book Other

BY CLICKING "SUBMIT" THE CLIENT AGREES TO SHARE THE INFORMATION ENTERED THROUGHOUT THIS FORM WITH Julie Cassidy ALL ANSWERS ARE CONFIDENTIAL AND WILL NOT BE SHARED WITH ANYONE ELSE BESIDES THE THERAPIST.

SIGNATURES WILL BE GATHERED UPON THE INITIAL APPOINTMENT.

Submit

Contact Julie Cassidy

<Counsellor> online intake forms

Save time with your first appointment by completing a secure and private online intake form.

online child and teen intake form

Online adult intake form

Contact Allyssha

* Indicates required field

Name *

First

Last

Email *

Message *

*Please do not send confidential information. Information that is exchanged between potential clients and counsellors are not protected until the necessary agreements are signed.

Send

Contact Colette

* Indicates required field

Name *

First

Last

Email *

Message *

*Please do not send confidential information. Information that is exchanged between potential clients and counsellors are not protected until the necessary agreements are signed.

Send

Saskatoon offices

COLETTE SILZER
BISW MSW RSW

Saskatoon, Sask – City Park Area – (she/her)
Evening and Weekend Appts
In Person, Virtual, and Phone Appts
City Park Office #1
306-321-7509
[email protected]

Read bio

JENNIFER BALLANTYNE
BSW RSW

Saskatoon, Sask – City Park Area – (she/her)
Day Appts
In Person, Virtual, and Phone Appts
City Park Office #2
306-361-8117
[email protected]

Read bio

GLENNA GOOD
BSW RSW

Saskatoon, Sask - Exhibition Area – (she/her)
Evening and Weekend Appts
In Person, Virtual, and Phone Appts
Willowgrove Office
306-321-4603
[email protected]

read bio

JOLEEN MALLORY
YCWC, BSW RSW

Saskatoon, Sask
Day, Evening and Weekend Appts
In Person, Virtual, and Phone Appts
2nd Avenue Office
306-270-4954
[email protected]

read bio

TAMMY ENS
CISW BISW RSW

Saskatoon, Sask - (She/Her)
Day, Evening, and some Weekend Appts
In Person, Virtual, and Phone Appts
2nd Avenue Office
306-270-4119
[email protected]

read bio

Bayani Trinidad
BA, BSW, RSW

Saskatoon, Sask (he/him)
Evening, Weekend, Appts In Person, Virtual, and Phone Appts
306-241-4793
[email protected]

read bio

Canwood / Prince Albert offices

read bio

ALLYSSHA OLSON
BA BISW BSW RSW

Canwood/Prince Albert, Sask – (she/her)
Day, some evenings, and select weekend Appts..
In Person, Virtual, and Phone Appts
639-922-7336
[email protected]

read bio

HEATHER CODY
BSW RSW

Prince Albert, Sask – (she/her)
Day, Evening, and Weekend Appts
In Person, Virtual, and Phone Appts
306-270-3994
hcody@thecounsellingcorner.ca

CHILD & TEEN THERAPY INTAKE FORM

This online form is intended for Children and Teens.

About you

* Indicates required field

Name of person completing this form: *

Your relationship to the child: *

Other parent/legal guardian

Name of other parent/legal guardian: *

About the child/teen

Child's date of birth (MM/DD/YYYY) *

Please enter the month, day, and year of the child's birth.

Home Address *

Who does the child live with? *

Parents are currently *

Name of child's school *

Grade *

Reason for your child's visit *

Medical history

Has your child been diagnosed with any conditions *

Please list any medications your child currently takes *

Please tell me about any other mental health professionals your child has consulted with in the past *

approximate dates, type of professional seen, reason for the consultation, nature of the treatment, outcome of the treatment.

Please list any family history of mental illness *

What are your goals for counselling *

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.

Please check all symptoms that apply (Part 1) *

Headaches Memory problems Depression Sleep problems Heart palpitations Feeling tense or nervous Academic concerns Ideas of harming yourself Drug use Worries about money Feeling shy around others Not confident Having a lack of friends Stomach problems Concerned about eating habits Feelings of panic, fear, phobias Trouble concentrating Alcohol use Feeling sad or depressed Grief or loss

Symptoms (Part 2) *

Nightmares Feeling restless Feelings of hopelessness Feelings of worthlessness Low self-esteem Disturbing thoughts Hallucinations Aggression Mood swings Recurring thoughts Chest pain Suicidal thoughts Trembling Sexual concerns Sexual identity concerns Anger Ideas of harming others Memory problems Chronic pain Blaming or criticizing self

Symptoms (Part 3) *

Abusing others Dizziness Feeling tired Feeling a need to be on the go Problems at home Anxiety Antisocial or illegal behavior Concerned about family members Irritability Abused by others Sick often Isolating self Disorganized thoughts Relationship problems Distractibility Impulsive Poor judgment

Please add any other information about your child that would be helpful for the counselor to know *

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.

By typing your name in this field you agree to your duties as the "Client", Identified in the paragraphs above. *

Please write your name

[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 [enter therapist's name].

signatures will be gathered upon the initial appointment.

Submit

Contact form sample

* Indicates required field

Name *

First

Last

Email *

Message *

*Please do not send confidential information. Information that is exchanged between potential clients and counsellors are not protected until the necessary agreements are signed.

Send

Contact <Counsellor name>

Adult intake form

BY CLICKING "SUBMIT" THE CLIENT AGREES TO SHARE THE INFORMATION ENTERED THROUGHOUT THIS FORM WITH Julie Cassidy ALL ANSWERS ARE CONFIDENTIAL AND WILL NOT BE SHARED WITH ANYONE ELSE BESIDES THE THERAPIST.​SIGNATURES WILL BE GATHERED UPON THE INITIAL APPOINTMENT.

Contact ​Julie Cassidy

Contact Allyssha

Contact Colette

Saskatoon offices

Canwood / Prince Albert offices

CHILD & TEEN THERAPY INTAKE FORM

by clicking "submit" the client agrees to share the information entered throughout this form with [enter therapist's name].​signatures will be gathered upon the initial appointment.

Contact form sample

THE COUNSELLING CORNER

BY CLICKING "SUBMIT" THE CLIENT AGREES TO SHARE THE INFORMATION ENTERED THROUGHOUT THIS FORM WITH Julie Cassidy ALL ANSWERS ARE CONFIDENTIAL AND WILL NOT BE SHARED WITH ANYONE ELSE BESIDES THE THERAPIST.

SIGNATURES WILL BE GATHERED UPON THE INITIAL APPOINTMENT.

Contact Julie Cassidy

by clicking "submit" the client agrees to share the information entered throughout this form with [enter therapist's name].

signatures will be gathered upon the initial appointment.