APPLICATION FOR COUNSELLING WITH BETH MARES RP
Full legal name: first_________________middle__________________last_________________
Date of birth: day ___ month ________ year ________
Business phone ______________ Cell phone _______________ Home phone ____________
email (please print very clearly) ____________________________
A confidential message may be left at/ sent to ________________________________
Family doctor ___________________________ Phone number_________________
Next of kin ___________________________ Phone number _____________ for emergency
Referred by: _____________________________________________________________
I am over 18 years of age. I am currently living in English Canada and/or I am a permanent resident of English Canada.
In the past year I have not threatened or planned suicide or homicide, engaged in self-harming behaviour such as cutting or burning, had a mental health emergency, used drugs other than marijuana illegally, had a sexual relationship with a minor (unless the authorities already know about it), been involved in domestic violence as abuser or victim, or been involved in violent or organized crime. I do not work in law enforcement or in any occupation that requires me to be armed.
I am aware that my counsellor does not do reports or write letters for custody. I agree that, should I be involved in legal proceedings, neither I nor my lawyer(s), nor anyone else acting on my behalf will call on my therapist to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless it is by mutual consent.
I agree to pay for each session by interac 48 hours in advance if it is in the office or 24 hours in advance if it is online, unless another arrangement has been made ahead of time.
I live in Toronto
While I do not anticipate that I will have a mental health crisis, I have prepared a crisis reference list, copy attached, which I keep for ready reference on ______________________________. [The list should include 911 and the phone numbers of the local crisis line and/or other local emergency service, any clinic where you are enrolled, any friends or relatives who might be able to help, a local taxi service if there is one, and the address of the nearest hospital emergency entrance.]
I am attaching this list along with the application form (or enclosing it if mailing a hard copy of the form).
I will pay for any in-office session cancelled less than 48 hours in advance for any reason or for any online session cancelled less than 24 hours in advance unless some other arrangement has been agreed upon ahead of time..
I understand that my counsellor does not provide emergency services, though I am aware that I am encouraged to inform her by email of any crisis or of any upsetting after-effects of a session.
I am aware that treatment for any disorder or dysfunction requires my informed consent, which I can withdraw at any time, and that I am encouraged to ask any questions I may have about how a treatment works, the expected results, any risks, alternative treatments, or the likely results of no treatment.
Confidentialility and records:
I am aware that my counsellor advises clients that counselling usually works better if they do not reveal the content of their sessions to family or friends, especially within 24 hours of the session.
I am aware that my counsellor will not be able to maintain confidentiality when she is obligated by law to do otherwise, or when she believes that someone is in danger of bodily harm. I also understand that the use of communication technology can compromise confidentiality.
Unless I instruct her otherwise in writing, I would like my counsellor to feel free to share information at her discretion with my family doctor, my psychiatrist if any, and any other psychotherapist or counsellor with whom I may be working concurrently.
I agree that when doing individual sessions in the context of couple therapy it will be my responsibility to make it clear what information, if any, should not be shared with my spouse.
I am aware that the notes on my sessions constitute a medical record which has to be retained by my counsellor for the mandated number of years, but that the first session is exploratory, and notes on it will not be preserved if I do not continue.
In order to protect my counsellor's privacy, I will not share any electronic or other records I may have of our work together without her written permission.
Signed __________________________________ Date_________________