T: 604.800.9010
T: 604.800.9010

IMPORTANT

Forms

Intake Form

Below are options for you if you are unable to use our online INTAKE FORM below.

WORD DOCUMENT | Print and Bring with You

 
 
PDF FORM | Print and Bring with You

 

ONLINE FORM

 

 

ONLINE INTAKE FORM

INTAKE FORM - BRENTWOOD COUNSELLING CENTRE

1. INTRODUCTION

The information you provide here is protected as confidential information. All info will be directed to Gloria Lee of Brentwood Counselling Centre.
First
Last
Address
2nd Address Line
City
State/Province
Zip/Postal
Country

2. HEALTH INFORMATION

Physician's Full Name
Psychiatrist's Full Name

3. EDUCATION, EMPLOYMENT

4. CHURCH, COMMUNITY AFFILIATION

5. FAMILY HISTORY

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member in the space provided (self, brother, sister, father, mother, uncle, etc)

By filling this out, it is a yes.

6. SELF ASSESSMENT

7. POLICIES

FEES AND PAYMENT: Fees are payable at the time of each visit, unless other arrangements have been made. You are responsible for payment regardless of third party involvement. If you fall behind in payments for more than two sessions, another session will not be scheduled until your account is paid or arrangements are agreed upon. Fees may be readjusted at any time. One month’s notice will be given for any increase. I charge for time needed to prepare written reports at the hourly rate. Fees are payable by cash, credit or debit. A receipt will be issued for third party reimbursement. CANCELLATIONS: The psychotherapy process involves meeting for a 1 hour session for individual counselling and 1.5 hour or 2 hour session for couples and families (unless other arrangements have been made). A specific time during the week has been reserved for you. If you must cancel due to illness, please notify me as soon as possible. Should you need to cancel for any other important reason, 48-hour notice is required, otherwise you will be charged for the session. Advance notice gives me time to reschedule and allow someone on the waitlist to be seen. TELEPHONE CALLS & EMAILS: I check my confidential email and voicemail, (604) 800.9010 daily, less frequently on weekends and holidays. For emergencies, please call 911. CONFIDENTIALITY: Psychotherapy is confidential except where limited by Canadian law. These exceptions include situations that involve child, elder, or dependent adult abuse or if a client is a danger to him or herself or others. Written permission is otherwise needed to disclose any information to a third party. When working with children and adolescents, it is my policy to regard everything said in session as confidential except where noted above. I will encourage the child or adolescent to disclose to the parent information regarding substance abuse, sexual activity, or other behaviour that places him or her at risk. TERMINATION: You have the right to terminate treatment at any time. It is helpful for us to discuss termination fully in at least one session. I may also terminate treatment if you do not comply with the conditions of treatment (i.e., coming to sessions clean and sober, refusal to obtain a psychiatric consult, consistent no shows). I may also terminate treatment and refer you to another professional if your issue is beyond the scope of my practice. I understand and agree to the guidelines listed above, to the statement of confidentiality, and to paying all the charges in full at each meeting.
By typing in your name, you have electronically acknowledged your agreement.