Intake | HappyFamilyTherapy

First name

Middle Name

Last name

Date of Birth

Day

Month

Year

Marital Status

Children Names and Ages

Do you have any pets? If yes, what kind? (e.g., cats, dogs, birds)

Address

What is your current occupation or daily role? (This could include paid work, caregiving, volunteering, studying, or anything else that reflects how you spend your time.)

Phone

Emergency contact name and phone number

Have you ever seen a Therapist\Counsellor\Psychologist or similar before? When and for how long?

Do you smoke? If so, how often?

Do you take any psychiatric medications?

Do you suffer from any medical chronic illness or mental health illness?

How did you hear about Happy Family Therapy Centre?

I have read and agree to the terms and conditions below

Signature

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Terms and conditions Confidentiality: Information from our sessions is protected. The following are exceptions: If one of you pose an imminent danger to yourself, your partner, or a third person. A child under the age of 18 or an elderly or disabled person is at risk of emotional, physical or sexual abuse, neglect, or exploitation. If you are not yet 18 years of age, your parents or legal guardians may have access to your records and may authorize release of information to other parties on your behalf. For emergencies or health concerns you should contact your GP as we do not provide emergency services. I, the client, understand that the services provided are for consultation and therapeutic purposes only. The therapist is not a medical doctor and does not provide medical or psychiatric treatment. No Guarantee of Success: I acknowledge that therapy outcomes vary and that my therapist\counsellor makes no guarantees or promises of specific results. The client can make an appointment to raise any concerns and to speak with the therapist immediately of any concerns provided that the therapist is likewise available to discuss matters with the client (during a paid appointment). Appointment fees will be paid for by the client in advance. Our cancellation policy requires a 72-hour notice (not including weekends). In the event that you will be unable to keep an appointment or reschedule, there will be no charge if you notify me 72 hours in advance. If I do not receive this notification you will be responsible for payment up to full fee. I will show up to my appointments healthy and not intoxicated. I understand and agree to the fees for services and the scheduling policies established. Client hereby assumes full responsibility for receipt of the counselling, therapy, conversation, activity and\or advice and releases and discharges Therapist and\or Counsellor from any claims, liabilities, damages, actions, or causes of action arising from the therapy\counselling\service received, including without limitation, any damages arising from acts of active or passive negligence on the part of the Therapist\counsellor, to the fullest extent allowed by law. I accept this agreement and consent to counselling and\or therapy.