THRIVE Counselling
777 Guelph Line, Suite 207
Burlington  L7R 3N2


Phone: (905) 637-5256,
Fax: (905) 845-3537
Referral Type:
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Referral:
Intake Form - New ID
Date: 2025-06-16 09:16
Status: Draft
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Hide/ShowClient #1 Info
Date:
Select Date Clear Date
First Name
Last Name
DOB
Select Date Clear Date
Gender
Address Line 1:
City
Postal Code
Province
Primary Phone Number:
Permission to call?
Permission to leave a message?
Alternate Phone:
Email:
OK to leave a message?
(select all that apply)
Alternate
Email
Emergency Contact Person
Emergency Contact Relationship:
Primary Phone
Alternate Phone
Emergency Contact requested (cannot provide)
Hide/ShowClient #2 Info

Please complete only if this is a couple or family service request. If not, scroll down to 'Next Section'

First Name:
Last Name:
Hide/ShowServices
Type of service
Individual
Couple
Family
Group
Reason(s) for the referral
Referral Source
Do you have fears for your safety or another family member?
Yes
No
Unsure
Has there been any abuse (i.e verbal, emotional, financial), violence or threats of violence in your family/household?
Yes
No
Unsure
Any Police and/or Court involvement or Outstanding Charges?
Yes
No
Unsure
Do you have any concerns regarding your substance use?
Yes
No
Unsure
Do you have any concerns regarding your family's substance use?
Yes
No
Unsure
Hide/ShowComments & Presenting Problems
Check all that apply
Anxiety
Problems with Relationships
Trauma
Abuse
Problems with Substance Abuse
Parenting
Depression
Separation/ Divorce
Other (describe below)
Grief/Loss
Financial Stress
Primary Concern(s)/ Comments:
Do you require accommodations for accessibility?
If you answer
Special Request (i.e. language, location)
Interpreter/ Intervener required?
Times Available:
select all that apply
Mornings
Afternoons
Evenings
Saturday
If you would you like to receive appointment reminders, please indicate preference
Via Email
Via SMS Text
Consent: Pressing submit will forward this information to the intake department. You will be contacted by intake to complete the next steps.
Hide/ShowLimitations To Confidentiality/Client Rights

The confidentiality of Thrive Counselling clients is of utmost importance to all staff.  The agency is required to obtain your informed written consent before releasing or obtaining any information except where authorized by legislation or directed by the courts.  These exceptions are as follows:

1.     In certain limited circumstances your counsellor/therapist is required by law to disclose client information, and must comply with these mandatory obligations. These circumstances include, but are not limited to:  significant concern about the safety of a child (physical or sexual safety) or significant emotional harm (which includes situations and/or behaviours that seriously interfere with a child's development or functioning); files being subpoenaed; search warrants.

2.     In addition, it is a condition of the counselling relationship that your counsellor/therapist will release what would otherwise be confidential information if there is reason to believe that you represent a significant and immediate threat of death or serious injury to yourself or others. Thrive Counselling will take whatever steps necessary to avert danger to a client or others.  The threat of harm will always take priority over confidentiality.  Thrive Counselling has adopted this policy for the welfare of our clients, staff and the community at large.

Additionally, in an agency such as ours, there is sometimes a need for your counsellor/therapist to share pertinent personal information within the agency to other professional staff, administrative staff, and appropriate accredited bodies, who are ethically and strictly bound to maintain confidentiality.

If you are concerned about any aspect of these limitations to confidentiality, please discuss your concerns with your counsellor/therapist.

Understanding of Limitations to Confidentiality
Yes, I understand the above limitations to confidentiality.
Consent to Services
Yes, I am consenting to counselling services (telephone, video, and/or in-person), understand that limitations described above apply to any direct or indirect information acquired through virtual contacts (telephone, email) and am providing my email address to Thrive Counselling.
 
Yes
No
Consent to Quality Assurance Review
Please indicate whether you are or are not willing to have the counselling record reviewed for quality assurance purposes by accreditation staff from the Canadian Centre for Accreditation.
 
Yes. I am willing to have my/our counselling record reviewed for quality assurance purposes by accreditation staff from the Canadian Centre for Accreditation.
No. I am unwilling to have my/our counselling record reviewed for quality assurance purposes by accreditation staff from the Canadian Centre for Accreditation
Your Rights
Please indicate that you have been informed of my/our rights as outlined in
 
Yes, I have read the Your Guide to Our Services information
Appointments
Yes, I am aware that non-attendance at appointments, late and frequent cancellations, or recurring rescheduling of appointments may result in discontinuation of the current service.
First Name:
Last Name:
Email:
Signature:
Hide/ShowConsent For Video Counselling

Client(s) understand that only Thrive's designated, secure platforms (e.g. doxy.me, Webex or Microsoft Teams) will be the means of conducting video sessions with the counsellor. There is no need for clients to download an app to access these platforms.

  • Client(s) login are expected to log in to the platform at least 10 minutes prior to each video counselling session.
  • Technical support is available on-line on the platform or by googling YouTube instructions.
  • Client(s) are responsible for the data usage & any other associated internet costs resulting from video counselling.
  • Video counselling is only available while physically located within the province of Ontario.
  • The location during sessions must ensure 1) privacy & 2) lack of interruptions.
  • To protect your privacy, we encourage client(s) to ensure that their computer/phone/mobile device is password protected in the event of loss.
  • Client(s) must show a photo ID confirming their name and date of birth in order to verify their identity and place of residence.
  • Client(s) understand that the counsellor may determine that video counselling is not, or is no longer appropriate, during the course of the counselling and will discuss other options.
  • Client(s) have been advised of and understand the limits of confidentiality and privacy that are unique to the video counselling process.
  • Client(s) understand that information gathered through video counselling sessions and any other means of electronic communication will be documented in their client file. Video and chat records will not be recorded or stored.
  • Client(s) shall not make or distribute any recording of video, audio, or chat content.

Client(s) understand that:

  • Fee paying clients can enter payment information into the doxy.me system during each video counselling session.
  • E-transfers are available through the counsellor for all other payments. Credit card payments are also available through the counsellor for clients using the Webex or Teams
  • Client(s) understand that half of the fee will be charged if it is determined by the counsellor that the video session cannot be conducted due to the client(s) being located in an inappropriate location or if the client(s) does not log in for the scheduled appointment.
Understanding and Consent
Yes, I understand and consent to the above Terms of Service specific to video counselling.
First Name:
Last Name:
Email:
Signature:
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