New Client Information Form New Client Information Form Date* MM slash DD slash YYYY Name* First Last Home Phone*Cell Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about the Candace Plattor methodology? (Check all that apply)* Google search CandacePlattor.com website Read her book, “Loving an Addict, Loving Yourself” Watched her YouTube video(s) Referral Psychology Today Counselling BC BCACC Other If you were referred, who can we thank? What are your top 3 goals for counselling?*Consent to Treatment: As we begin working together, there are a few things about the counselling process that you need to be aware of. This is to let you know what counselling involves, what you can expect, and what your rights are as a client. It also gives us a chance to talk about any questions you might have.* I understand and consent. I want to discuss this with my counsellor. Benefits: Counselling can result in many positive changes and an overall better quality of life. It can help you understand your challenges and find better ways to deal with them. There are no guarantees, however, because the changes you make will depend on you, since you are responsible and free to make your own choices.* I understand and consent. I want to discuss this with my counsellor. Length of Treatment and Termination: The term of the Family Addiction Therapy Program is usually 3 to 6 months. During that time, we will provide counselling for you and any members of your family who are feeling negatively affected by addiction – including for the addicts themselves, when they are ready.* I understand and consent. I want to discuss this with my counsellor. Confidentiality: We will not share your information with anyone outside of your family without your written consent, with the following exceptions as discussed below (see Limits of Confidentiality). In couple and family counselling, we do not guarantee confidentiality when we see people individually.* I understand and consent. I want to discuss this with my counsellor. Note-taking: We will keep brief notes for each session. These are primarily for your benefit, since they help to keep track of important information and our general process. They are stored in a locked cabinet for security. Under the Freedom of Information and Privacy Act, you have a right to have access to the information in your file. Your file is open to you at any time, and we will be happy to show your file to you whenever you ask to see it.* I understand and consent. I want to discuss this with my counsellor. Limits of Confidentiality: We will discuss issues of confidentiality as they come up. However, it is important for you to know that there are several situations under which we legally cannot maintain confidentiality. These are: 1. If you intend serious harm against yourself (including suicide) or others. 2. If we hear about or suspect child abuse or neglect. 3. If our case notes are required for court, either court-ordered or subpoenaed.* I understand and consent. I want to discuss this with my counsellor. Third Party Billing: If these sessions are billed to a third party (such as an employee health plan or insurance), we may be required to share information with them and thus cannot guarantee confidentiality. Also, a diagnosis is often necessary for third party billing, and it can become a permanent part of their file, which may not be kept confidential.* I understand and consent. I want to discuss this with my counsellor. Fees and Appointments: Each therapy session is 60 minutes long, and all sessions are covered in the fee for the duration of the Family Addiction Therapy Program. If you need to cancel your appointment, we ask that you let us know with at least 24 hours notice. Your appointment is a time reserved just for you, and by giving enough notice it allows someone else to use that time. Please feel free to ask us about this if you have any questions.* I understand and consent. I want to discuss this with my counsellor. Licensing and Credentials: Candace has an M.A. in Counselling Psychology from Adler University, which is accredited with both the Canadian and American Psychological Associations. She is a Registered Clinical Counsellor with the BC Association of Clinical Counsellors (#1874). She, and the therapists who work with her, follow the Canadian Code of Ethics for Psychologists, published by the Canadian Psychological Association. If you would like more information about this, please feel free to contact the BC Association of Clinical Counsellors, at 250-595-4448.* I understand and consent. I want to discuss this with my counsellor. Please provide the name and email address you want to appear on your receipts.* If you will be submitting your receipts for reimbursement by an insurance carrier, what is their preferred format?* One receipt per full payment. Individual receipts per prepaid sessions. Acknowledgement: By clicking the checkbox below and submitting this form, I acknowledge that I have read this form and discussed my questions and concerns with the counsellor.* I understand and agree to the general terms outlined here. Δ
