Personal Information & Consent Form for Adults Do not fret about these forms! If any questions don’t apply to you or your situation, please feel free to leave them blank. Personal Information Form Name * First Name Last Name Email * Date of Birth MM DD YYYY Emergency Contact (Name, Phone Number, and/or Email) Postal Code What Country are you from/currently residing? Pleast list any significant health issues and/or medications. Briefly (a few sentences or a short paragraph) tell me the main reasons why you are choosing therapy and/or counselling. Have you participated in therapy and/or counselling in the past, and if so what was your experience like? Please share any specific concerns you would like to address in therapy and/or counselling. What do you want to experience and/or change as a result of working together? Please share anything else that you would like me to know at this time. What is your preferred method of contact? Text Phone Email Thank you! Consent Form Name * First Name Last Name Consent Form * It is important that you know your rights and responsibilities of informed consent and therapy for both the client and the counsellor. Confidentiality is essential to the therapeutic process. You need to feel safe sharing your story and know that it will never go beyond us. I am ethically and legally required to maintain complete confidentiality at all times with the exception of the following situations: 1. If you are determined to be in imminent danger of harming yourself or others 2. If you disclose abuse or neglect of a child, the elderly or any vulnerable population 3. If a criminal court subpoenas my records Counselling and Coaching Appointments Therapy results in better outcomes when clients attend and schedule appointments consistently and regularly. I ask for 24 hours notice of any cancelled or rescheduled appointment. If cancelled with less than 24 hours notice, please understand that you will be charged the full amount for the session. Please contact me in case of emergencies – I understand that life happens. Fees Fees vary depending on the service provided. Please check my website at braatentherapy.com/investment for an outline of those fees. All payments are to be made prior to the session unless an alternative payment plan is discussed and agreed upon. Please check your insurance company as you may have coverage. I do have a small number of sessions available for a reduced fee for those who are financially unable to pay the full amount. Please contact me to learn if you qualify. Online Therapy Consent I will be using ZOOM as a software platform to conduct all online therapeutic services. I provide the highest possible security protection and your personal information is encrypted and stored on a secure server in compliance with PIPEDA, HIPPA, and HITECH guidelines. I will not use Facetime or Skype due to security and privacy protection. The client is responsible for securing the privacy of their own computer and in choosing a quiet, secure, and private location for each therapy session. There are always risks when using online software. In signing this form, the client acknowledges that confidentiality may be breached through using online software and waive Brenda Braaten Modern Counselling and Coaching of responsibility in the event a breach occurs. If a session connection is lost, I will initiate a re-connection. In the event that reconnection is not possible, I will call the client and the session will continue by telephone. Please have your phone nearby. The Counselling Experience Counselling and coaching with me will be a collaborative partnership. I will walk with you as you commit to learning, exploring, growing, and positive change. This journey can be life-changing and greatly successful when we both assume an active role in this experience. I commit to being fully present in your sessions and to serve you to my greatest capability. I welcome your feedback at all times and please know that you are never obligated to share or answer any question; you are always free to pass. This is your story, in your time, in your way! Agree Disagree Thank you!
