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Intake & Consent

Preferred method of communication
Are you currently experiencing difficulties with any of the following?
Shame/Guilt
Fear
Prolonged anxiety
Victim mentality
Sadness
Regret
Greed/Not feeling satisfied
Anger/Aggression
Hatred
Sense of being stuck or lost
Eating pattern disruptions
Sleep disruptions
Depression/Apathy
Suicidal ideation
Do you consider yourself a spiritual or religious person?
Yes
No
I don't know
Do you have insurance that covers master's-level social work services?
Yes
No
Please provide the birthday of the insured member.
Year
Month
Day

Therapy Fee Agreement

Counselling appointments last between 50 and 60 minutes and end at the scheduled time. If you're late, we'll still finish at the original time to respect everyone’s schedule. The session fees are listed at the time of booking. However, if you do not have extended benefits, please notify us, and we can discuss flexible payment options and sliding scales.

Cancellations

Please cancel any appointment at least 24 hours in advance. If you cancel less than 24 hours before your session, a $50 fee will be charged for the time spent planning your session. Exceptions may be made for emergencies at our discretion.


Payments via e-transfer or cash must be made before the start of each session. This contract is solely with Direct Connection Services.


By signing below, you acknowledge your payment responsibilities and accept the terms of this contract, constituting informed consent for therapy with Direct Connection Services.

Counselling Informed Consent

This information outlines what you can expect from Direct Connection Services and details how your personal information will be collected, used, and protected. As professionals, we are dedicated to safeguarding your privacy and have established policies in line with the Personal Information Protection and Electronic Documents Act (PIPEDA) and the Personal Health Information Protection Act (PHIPA).


Please ensure that you agree with the following statement by checking each box prior to signing at the bottom of the form.
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