May we leave a detailed message on your answering machine?*
Have you used our services before?*
Address (street, apt, city, province, country, postal code)*
Gender: How do you identify?*
Languages Spoken (check all that apply)*
Are you 18 years of age or older?*
Are you currently employed?*
Do you have benefits for counselling and psychotherapy?*
If you do not have benefits are you aware of our fee? ($155 a session)*
Please provide a brief summary of reason for seeking therapy*
How long has the above issue(s) been occurring for?*
What would you rate the intensity of the above issue(s) on a scale of 0-10? (0 meaning nothing in severity and 10 meaning the worst it could be)*
What type of psychotherapy are you seeking? (check all that apply)*
Are you comfortable working with a female therapist?*
Do you have any other preferences for a therapist?*
Have you been prescribed medication for the issue(s) you are facing?*
What medication have you been prescribed? Please include the name of the medication and its dosage.
Any changes in lifestyle? (hours of sleep, lost or gained weight, changed eating habits etc). Please describe them below. *
Have you obtained previous counselling?*
If you have had previous counselling, please include when it was and what it was for.*
Are you seeking therapy to address violence/abuse? (e.g emotional, verbal, sexual, etc)*
Are you in fear for your own safety?*
Are you in a state of distress?*
Are you seeking therapy to address trauma or substance use?*
Have you been mandated to obtain counselling and psychotherapy?*
Have you been involved with the police, legal system, or CAS in relation to the reason you are seeking therapy?*
All of the information I provided in this form is true and accurate to the best of my knowledge.*
In submitting this form I am aware that if the therapist has reason to believe that I am at risk of seriously harming myself or another person, a child is at risk of being harmed, a health professional is harassing or abusing me, or the file is subpoenaed, the therapist would be required by law to make a report in order to protect me and/or the individuals involved. *
In submitting this form, I am also aware that internet transmission cannot be guaranteed to be secure or error-free, as information could be intercepted, corrupted, lost, destroyed, arrive late or incomplete, or contain viruses. By interacting with Reflections Counselling and Psychotherapy Services (ReflectionsCPS) via submission of this form, I acknowledge that I understand the risks of e-communication and agree to indemnify ReflectionsCPS from liability resulting from these risks. If the information that I am providing is of a sensitive nature, I am aware that I may, alternatively, choose to contact Reflections by telephone.*
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