Relationship Counselling Edmonton AB | Family Counselling in Edmonton

Date

Name*

Address*

Phone*

Email*

Date of Birth*

Emergency Contact Name*

Relationship*

Emergency Contact Phone*

Marital status*

Single
Married
Divorced
In Relationship

Spouse/Partner’s Name*

Children?

Yes
No

Name

Age

Have you had any prior counseling, psychotherapy, or psychiatric treatment? Dates:

Yes
No

Have you had

Any Prior Counselling
Any Psychotherapy
Any Psychiatric Treatment

Date

Have you ever been hospitalized for psychiatric treatment? If yes, please provide dates and place of Treatment.

Yes
No

Date

Place of Treatment

Have you ever taken medication for emotional benefits? If yes, please state dates, medication and Dosage.

Yes
No

Date

Medication and Dosage

Are any other family members currently receiving counseling, psychotherapy, or psychiatric treatment?

Do you or any family members have a history of significant physical illness or health issues? If so, please explain.

With whom do you live? Please provide names, ages, and their relationship to you. Please describe your family of origin. Include parents, siblings, and note their names and ages. Please indicate your place in the birth order.

Please also include any other information you think is significant about the family you grew up with.

Please describe your general health. Include how you usually feel. Include things such as fatigue, sleep disturbances, bowel and bladder problems, muscular tension, chronic pain, headaches (frequency and intensity), diseases and surgeries. Please include any other information you think is important for me to know about.

Name of your medical doctor

Do you exercise?

Yes
No

Describe

What medications do you take on a regular basis?

Please describe your use of substances such as alcohol, cigarettes, caffeine, or other recreational drugs.

Describe what you like to do for enjoyment and pleasure. Describe hobbies, special skills, etc.

Please use this space to add anything else you would like me to know about you, your work, your family, or personal relationships.

Are you covered under a health insurance plan?

Yes
No

Please check with your health provider to see if they cover registered counsellors. I am not a psychologist or a social worker and some plans only cover those types of services.

Terms and Conditions

Cancellation and missed appointment policy:

I require a minimum of 48hrs to cancel or reschedule an appointment. I will reschedule your appointment in the same week if I have a space available. If I do not have a space available you will be billed for the session that you have cancelled.

Confidentiality:

No information will be shared or disclosed to anyone without permission from you.

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.

My email guidelines are as follows:

1) At my discretion and for established clients only.

2) For setting up and/or changing appointment times.

3) For non-urgent issues.

4) When I can address the concern with a single reply, requiring 5 minutes or less.

5) E-mail correspondence entailing more than 5 minutes of time for reply will be subject to my hourly fee for service

6) If an e-mail requests my assistance for an issue or situation that, in my opinion, cannot be properly addressed by e-mail, you will be notified by return e-mail to schedule an appointment for an office visit or telephone consultation (whichever I consider most appropriate to provide good care) within the timeframe recommended. In this case no treatment recommendations will be provided by e-mail, to provide the highest standards of care.

E-mail communications are not to be used as a way to temporarily or permanently end our work together. If you wish to complete your work with me, or take a temporary break due to vacations, work schedules or other life circumstances, please discuss this in person with me, and please allow adequate time for us to consider this together.

I have read and understand and agree to the Terms and Conditions for working with Tom Burton.*

I have read and understand and agree to the Terms and Conditions for working with Tom Burton.

Intake Form

Terms and Conditions

Cancellation and missed appointment policy:

Confidentiality:

Litigation Limitation:

My email guidelines are as follows:

“Tom Burton Counselling offers Clinical Transactional Analysis (CTA) therapy and counselling services for healthcare professionals, individuals, musicians, and couples in Edmonton, AB Canada.”

Address

Hours