Personal Information and Consent form Minors 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 Phone (###) ### #### 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 Below 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 consensus 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 What is the name of your First Legal Guardian? First Name Last Name What is the phone number of your First Legal Guardian? (###) ### #### What is the email of your First Legal Guardian? What is your relationship to your First Legal Guardian? What is the Name of your Second Legal Guardian? First Name Last Name What is the phone number of your Second Legal Guardian? (###) ### #### What is the email of your Second Legal Guardian? What is your relationship to your Second Legal Guardian? 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. 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! 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. Consent for Minors It is important that you as a parent or legal guardian, along with your child/adolescent, know the rights and responsibilities of informed consent and therapy for both the client and the counsellor. I prefer to have the first session with the parent(s) or legal guardians along with your child/adolescent present. In this initial connection, I will gather information, the reasons for seeking therapy, and the goals that you as a parent have for the counselling sessions. The goals and perspective of your tween or teen will also be addressed and honoured. If you believe that an initial discussion could in any way negatively impact your child, we can discuss and arrange to connect without them present if necessary. I can also immediately meet with your tween or teen without your attendance if that is preferred by you and your young person. Once therapy begins with your tween or teen, I will not divulge any information that they share with me in the counselling space. I will discuss with your tween/teen at the close of each session, what I can and cannot share with you. I am ethically and professionally bound to confidentiality at all times with the exception of your tween/teen indicating that they are in imminent danger to harm themselves or others or when a court of law subpoenas counselling record. Agree Disagree Thank you!
