Client Forms

Client Forms

Please, review, print, and sign the documents or forms that are applied to you before your first visit. It will allow us to immediately get underway with your initial visit.

Also, please review carefully and have ready any questions you might have. Forms will also be available in the office at the time of your first visit if needed.

To open the downloadable PDF or MS Word document, please click on the file name.

Client Personal Profile – PDF Client Personal Profile – MS Word

The Client Personal Profile is a questionnaire that contains various questions relating to you, your family, and your life experiences. Please read, complete the questionnaire, and bring the Client Personal Profile with you to your first session and your counsellor will go over it with you. We recommend for you to not email this document since it contains your personal information and any Internet-based communication is not guaranteed to be secure/confidential. However, if you choose to send your completed Client Personal Profile via the internet, we cannot take responsibility for any risks involved. If this is your personal choice, then you can email it to ivana@purposefullivingcounselling.com

Informed Consent (Adult)

The Informed Consent (Adult) is a legal document containing a contractual agreement between the client and the counsellor. It describes the rights and responsibilities of both parties. Please read and bring the Informed Consent with you to your first session and your counsellor will go over it with you. At this time, both you and your counsellor will sign the Informed Consent. You will retain a copy and your counsellor will retain a copy which will be placed in your file. Do not email this document since it requires your original signature and contains your personal information.

Informed Consent (Adolescent)

The Informed Consent (Adolescent) is a legal document containing a contractual agreement between the client and the counsellor. It describes the rights and responsibilities of both parties. Please read and bring the Informed Consent with you to your first session and your counsellor will go over it with you. At this time, both you and your counsellor will sign the Informed Consent. You will retain a copy and your counsellor will retain a copy which will be placed in your file. Do not email this document since it requires your original signature and contains your personal information

Informed Consent For Minors

The Informed Consent for Minors – 12 Years and Under is for you as the child’s legal guardian/ parent to complete on behalf of your child.

The Informed Consent for Minors is a legal document containing a contractual agreement between the client and the counsellor. It describes the rights and responsibilities of both parties. Please read and bring the Informed Consent with you to your first session and your counsellor will go over it with you. At that time, both you and your counsellor will sign the Informed Consent. You will retain a copy and your counsellor will retain a copy which will be placed in your file. Do not email this document since it requires your original signature.

Application For Fee Reduction

It is our desire to offer compassionate help when life becomes a struggle. We believe that no one should suffer alone. To make counselling more affordable for anyone who requires services but cannot afford a full fee, we adjust our fees based on your gross household income. There is a limit on availability to subsidize and reduce fees. Reduction of fees will periodically be reviewed. Please complete the Application for Fee Reduction and bring it into the Purposeful Living Counselling Clinic.

Referral For Counselling

Purposeful Living Counselling Clinic would like to thank the person and/or agency that referred you to our Clinic. If applicable, we also would like to invoice the person and/or organization for the full rate or sliding scale rate for the counselling session(s) fees. Therefore, with your permission, could you please complete the Referral for Counselling form that is applicable to you and bring it to the Purposeful Living Counselling Clinic. Thank you.

Contractual Agreement

This contractual agreement is between the Purposeful Living Counselling Clinic and Client concerning Client’s Insurance coverage for counselling services provided

Couple, Marital, and Family Life History Questionnaire

The purpose of this questionnaire is to get a complete picture of your couple, marital, and family background. In marriage and family therapy we are concerned with issues that impact on you, your marriage, and your family from many sources. Therefore, answering these routine questions, as fully and as accurately as you can, will make it possible for us to work on the things that concern you much more quickly.

Authorization for Release of Information (Adult)