Counselling Agreement Please enable JavaScript in your browser to complete this form.1234567With regard to the counselling relationship, I offer a personalized approach tailored to each client’s unique and individual needs for both short-term and long-term counselling. I ensure that my clients can connect with their authentic selves in the warm and safe private setting of their homes, and I utilize a strength-based humanistic approach grounded in a holistic biopsychosocial perspective. Together we will discuss their unique experiences, thoughts, and feelings; and, at their discretion, we will develop a plan that will best suit their needs. We will also periodically reevaluate the changes that they have made and develop more accurate plans, as required. This document contains important information about my professional services and business policies. It is important that you read the following information carefully; one signed copy is for my files, and I will provide an additional copy upon request. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign it or at any time in the future.NextCounselling Agreement With regard to our counselling relationship, I offer a personalized approach tailored to the unique and individual needs of each client in both short-term and long-term counselling. I provide a warm and safe place for my clients to connect with their authentic selves in a private setting and utilize a strength-based humanistic approach grounded in the holistic biopsychosocial perspective. Together we will discuss your unique experiences, thoughts, and feelings; and at your discretion, we will develop a plan that will best suit your needs. We will periodically reevaluate the changes that you have made and develop more accurate plans, as required. The following are the requirements of counselling. Please check off each one as you read it.Appointments Checkbox *Appointments: Individual counselling sessions are 50 minutes in length, and we can most effectively achieve our goal(s) in weekly appointments. Twice a week might be appropriate for a short period based upon individual circumstances.Lateness Checkbox *Lateness: If you are 20 minutes late for a session, I will consider the appointment a missed session and charge you. If you are late your appointment will not run into the next client’s time. I also have the right to change my schedule.Cancellation Checkbox *Cancellation: I require at least 24 hours' notice by phone or email for session cancellation or rescheduling. Sessions with less than 24 hours' notice are subject to billing at half the session fee; sessions with less than 12 hours' notice and no-shows are charged at the full session fee. Contact Checkbox *Contact: I will attempt to return messages as soon as possible Monday through Friday (except holidays) or within 48 hours at the latest. You can schedule appointments by telephone, email, or by using the online booking portal.E-counselling Checkbox *E-counselling: E-counselling involves the use of electronic technology media, which can include telephonic, email, or video-based platforms. The video-based platforms that I use are user friendly, secure, specific-service tailored, and designed applications for e-counselling; they have PIPEDA/PHIPA/HIPAA-compliant security protocols. Telephonic and email platforms are a risk because they are not secure, and texts are not appropriate for this purpose because of the risk of sending them to a wrong number. I cannot ensure the confidentiality of any form of communication through electronic technology media. When E-counselling support requires texting or contact via email to arrange, cancel, or change appointments, I will keep personal information to a minimum to protect your privacy. Please use only your first name and the initial of your last name in the text or email.Note Checkbox *Note: Audio or video recordings may be used to aid the counselling process and to gain further understanding of important aspects of the treatment. An informed consent document will be provided on recordings.If you are feeling in crisis, dial one of the following crisis lines: 911 if this is an emergency Or the Kamloops Mental Health Emergency Service: 250-377-0088 Or the First Nations Help Line: 1-855-242-3310 (24/7 – 365 days - serves all of Canada) Or the Trans Life Line (Transgender Suicide Hotline): 1-877-330-6366 Or the BC Interior crisis line: 1-888-353-2273 (24/7 - 365 days) Or the Crisis line: 310-6789 (no area code required) Afterward, please contact me to arrange an appointment.Counselling Agreement Signature *Clear SignatureI agree that I have read and understand the information above.Counselling Agreement Signed Date *NextConsent for Treatment and Statement of Confidentiality It is important that you know that your counselling sessions are confidential, restricted only by the Limits of Confidentiality outlined below. In addition, I regularly consult with a clinical supervisor, who is bound by confidentiality, in private supervision sessions on case reviews, case discussions, and video/audio tape reviews. I will keep all communications and records related to your counselling confidential and lock them in a secure place for a maximum of 7 years. Any release of information to any other individual or professional agency will require your written consent and be time limited, and you have the right to withdraw consent at any time. Counselling is voluntary, and you may refuse to participate at any time. Counselling can provide greater self-awareness, insight, and coping. Counselling may require that you consider exploring difficult topics, or memories, and try new behaviours. These experiences can sometimes lead to stronger than usual emotions. The counselling process will help to manage these feelings; however, this requires cooperation between me and you, as well as your willingness to disclose when emotions become difficult to manage. Clients should be aware that the counselling process poses certain inherent risks. While we work together, additional problems might surface of which you might have been unaware before counselling. Further, counselling might cause changes in relationship patterns and/or unpredicted responses from individuals in the client family system. Counselling is a collaborative process between me and you, it is not prescriptive in nature.Limits of Confidentiality The following practices are very important. Please discuss with me any information that you do not understand. Please check the boxes to acknowledge that you understand the practices.If you are under the age of 19 and disclose abuse (sexual and/or physical) from a specific person, I must report the abuse to the Ministry of Children and Family Development. *If you are under the age of 19 and disclose abuse (sexual and/or physical) from a specific person, I must report the abuse to the Ministry of Children and Family Development.If you are over the age of 19 and disclose abuse (sexual and/or physical) from a specific person who has access to people under the age of 19, I must report the abuse to the Ministry for Children and Family Development. *If you are over the age of 19 and disclose abuse (sexual and/or physical) from a specific person who has access to people under the age of 19, I must report the abuse to the Ministry for Children and Family Development.If there is a possibility that you might seriously harm yourself or others, we must take reasonable action, which can include contacting the police. *If there is a possibility that you might seriously harm yourself or others, we must take reasonable action, which can include contacting the police.If I suspect any form of abuse, sexual assault or neglect of a child or adolescent, incapacitated adult or elderly individual, I must take reasonable action, which can include contacting the Ministry of Children and Family Development or designated agency and the police. *If I suspect any form of abuse, sexual assault or neglect of a child or adolescent, incapacitated adult or elderly individual, I must take reasonable action, which can include contacting the Ministry of Children and Family Development or designated agency and the police. If you are impaired by drugs and/or alcohol and intend to drive, we must report this to the Motor Vehicle Branch and/or the police *If you are impaired by drugs and/or alcohol and intend to drive, we must report this to the Motor Vehicle Branch and/or the policeIn some court actions, your counselling file can be subpoenaed. This is not a frequent occurrence; however, you should be aware of the possibility. *In some court actions, your counselling file can be subpoenaed. This is not a frequent occurrence; however, you should be aware of the possibility.Consent If you wish that I contact other persons or parties to discuss your treatment and coordinate care, please request a Release of Information authorization form from me, and we will discuss any release of information in advance.Confidentiality Signature *Clear SignatureI agree that I have read and understand my rights to confidentially as explained above.Confidentiality Signed Date *NextFee Agreement Services I provide counselling services to individuals, couples, and families. My clients are of all ages and come from diverse backgrounds with diverse issues. Individual Counselling: 50 min/hr. $150+GST (50 minutes counselling and 10 minutes administration). 90 min. sessions are available upon request $225/90min. (80 minutes of counselling 10 minutes of administration). Couples Counselling: 50 min/hr. $175 +GST. The first session may be either 50 min/hr. ($175+GST) or 90 min. ($262.50+GST), depending on the couple’s needs (90 min = 80 minutes of counselling 10 minutes of administration). The second session may be an individual session ($150+GST) with each partner 50min/hr., and the third and subsequent sessions as a couple are 50 min/hr. ($175+GST) or 90 min. ($262.50+GST), depending on their needs (90 min = 80 minutes of counselling 10 minutes of administration). In addition, I might recommend that you complete a research-based online questionnaire as part of the assessment process. You may be charged the fee for completing the questionnaire. If you terminate treatment at any point during the assessment process and resume at a later date, the fee will be added to the next session’s fee. Family Counselling: 50 min/hr. $200 +GST: May require individual sessions with each family member ($150+GST for 50 min/hr.) and family sessions ($200+GST for 50min/hr., or $300+GST for 90 min.), depending on their needs (90 min = 80 minutes of counselling 10 minutes of administration). Payments I am an approved provider with some insurance companies or managed-care companies that I might be able to bill directly for you. You will need to contact your insurance company if you are seeking reimbursement for my services, and they can help you coordinate these benefits. Payment by e-transfer is acceptable at the time of the session. A receipt will be provided upon receipt of payment. It is an important benefit to society in general that every person have an opportunity to access counselling support. Therefore, we might respectfully negotiate a sliding scale depending on the circumstances but limit the sessions to be mindful of the need to avoid causing unnecessary distress for the individual. We will reevaluate the fees and circumstances at the eighth session, when we also reevaluate the counselling goals.Fee Signature *Clear SignatureI agree that I have read and understand the fee structure.Fee Signed Date *NextIntake FormIntake Form Completion DateFull Name *Date of Birth *Address *Address Line 1CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryLength of time at this address? *Contact InformationHome PhoneOK to leave a message on your home phone?YesNoCell PhoneOK to leave a message on your cell phone?YesNoWork PhoneOK to leave a message on your work phone?YesNoEmail *OK to send you an email? *YesNoPreferred Contact Method *Choose oneHome PhoneCell PhoneWork PhoneEmailIn Case of EmergencyPhysician *Physician Phone *Physician Address *E-counselling Contacts - In Case of EmergencyContact (#1) Name *Contact (#1) Phone *Contact (#1) Relationship *Contact (#1) Alternate PhoneContact (#2) Name *Contact (#2) Phone *Contact (#2) Relationship *Contact (#2) Alternate PhoneContact (#3) Name *Contact (#3) Phone *Contact (#3) Relationship *Contact (#3) Alternate PhoneE-Counselling Contacts Consent *I give my consent for Wade R. Alexander to contact the above person(s) in the event of an emergency. This includes the loss of e-counselling communication platforms (telephone, video) that cannot be re-established. I understand that he might need to provide confidential information to the above contact(s) regarding my file in case of emergency.Emergency Contacts Consent Signature *Clear SignatureI agree that I have read and understand the emergency contacts information and give my consent for Wade R. Alexander to contact the above person(s) in the event of an emergency.Emergency Contacts Consent Signed Date *Referral InformationName of person/organization that referred you *Identifying InformationGender assigned at birth *Sexual orientation/gender identity *Relationship status *Relationship status duration *How many siblings? *Position amongst your siblings? *Role amongst your siblings?Children (names/ages) *Culture and ancestry *Born & raised where? *Religious practice or spiritual belief *Does your religion add to your current conflict? *YesNoEmployer *Length of employment *Position *Income *Disability/Social Services? *YesNoOn probation/parole/forensics? *YesNoAnything that you want me to know about you?NextCounselling HistoryAny previous counselling experience? *YesNoIf you answered yes, please elaborate below as to where, when and how the experience was for you. *Do you have any questions or concerns about counselling? *What brings you in today? *What do you expect from counselling? *When did your concern [or problem] begin? *Did any life changes or significant events occur at the time? *What will you do differently as a result of counselling? *Have you felt that you need to or ever attempted to harm yourself or others within the past year? *YesNoHave you had thoughts of suicide or attempted suicide within the past year? *YesNoDo you drink, smoke, use drugs, or abuse over-the-counter drugs/medications? *YesNoWhich ones and how often? *Suspect any addiction or feel addicted to anything? *YesNoTo what are you suspecting an addiction? *NextBrief Health HistoryDate of last physical exam *Any long-term health concerns/surgeries *Related medications/dosageMental health/psychiatric disorder(s) *YesNoDisorder type(s) *Related medications/dosage *Psychiatric admissions *YesNoDate(s) of psychiatric admissions *Health professional(s) involved *EmailSubmit