Client Intake FormPlease fill out this form after you have booked in for your intake session. Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Person who referred you/How did you find Kaitlin Counselling. Your age and occupation Name and age of partner or spouse (if seeking couples counselling) Emergency Contact Information Names of any mental health professionals you have seen recently or in the past. Significant health problems? Medications: * Briefly tell me why you are pursuing counselling at this time... Please share any specific concerns you would like me to address in our sessions... What do you want to experience as a result of working together? * Anything else you would like me to know at this time... Do you prefer video or phone? Confidentiality Agreement - Please carefully review the following information. Confidentiality is an important aspect of your counselling, so please feel free to ask any questions at any time. Counsellors have a primary obligation to respect the confidentiality of information obtained from persons in the course of their work as counsellors. They reveal such information to others only with the consent of the person or person’s legal representative, or in unusual circumstances in which not to do so would result in clear danger to the person or to others. Where appropriate, counsellors inform their clients of the legal limits of confidentiality, which are: The therapist may be required to give evidence if subpoenaed by a court of law; The therapist may report concern to appropriate persons if there is reason to believe that as a result of a client's actions the life or well-being of any person might be endangered; The therapist will inform the Ministry of Child and Family Development if there is suspicion that a client is responsible for a child being abandoned, deserted or maltreated. *Supervision being an exception * I have read and understand the above confidentiality agreement. Thank you!