Individual intake form

Name: Tom Burton Counselling
Address: 7718 104 St NW #201, Edmonton, Alberta, T6E 4C5, Canada
Telephone: +5873725638
Price range: $$

Date
Date Format: MM slash DD slash YYYY
Name*
First Last
Address*
Street Address City Province Postal Code
Phone*
Email*
Date of Birth*
Date Format: MM slash DD slash YYYY
Occupation
Name of Employer /Workplace
Emergency Contact Name*
Relationship
Emergency Contact Phone*
How did you find out about me? Referral source
Counselling Coverage?
I am a Registered Master Therapeutic Counsellor with the Association of Cooperative Counselling Therapists of Canada.
Provider Name
Please briefly summarize why you are seeking therapy and the outcome you hope to achieve:
Cancellation and Missed Appointment Policy

Tom Burton requires 24 hours’ notice to cancel or re-schedule an appointment.

Late cancellation fee: $75 for an individual session and $100 for a couple’s session.

There is a range of valid reasons for cancelling an appointment. In order to be consistent with all clients, cancellation fees will only be waived in the event of a medical emergency requiring urgent professional treatment, a death in the family, or a natural disaster.
Confidentiality

No information will be shared or disclosed to anyone without permission from you. Tom does not keep secrets between people when working with a couple or a family unless a prior arrangement has been made.
Exceptions to confidentiality: 1)Federal or Provincial Court requires information. 2)Criminal code violations where physical and/or sexual abuse of children are involved. 3)Situations in which any person’s life or health is in obvious danger.
Litigation Limitation

Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
I understand and agree to the above:
Print Name
Date
Date Format: MM slash DD slash YYYY
Signature*
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Tom Burton Counselling

Call

(587) 372-5638

Address

7718 104th Street

Suite 201

Edmonton

Alberta

T6E 4C5

Email

tburtontherapy@gmail.com

Individual intake form

Cancellation and Missed Appointment Policy

Confidentiality

Litigation Limitation

I understand and agree to the above:

Tom Burton Counselling

Call

Address

Email