New Client Registration Form

New Client Registration Form

Welcome to Canada Online Therapy.
Thank you for choosing our service.

We are thrilled to work with you and look forward to helping you improve your quality of life. 

Canada Online Therapy's New Client Registration Form for therapy gathers essential demographic, contact, medical, insurance, and emergency contact details, alongside a brief summary of the reason for seeking treatment.  

Our New Client Registration Form includes informed consent, HIPAA compliance, and office policies.  

Key Components of a Therapy Intake Form: 

Client Information:

Name, address, phone (with consent to leave messages), email, DOB, gender, sexual identity. 

Emergency Contact:

Name, relationship, phone number. Medical Information:
Primary physician, current medications, past medical/psychological history. 

Insurance Details:

Provider, ID number, policyholder info.  Reason for Treatment:
Presenting concerns, goals for therapy. 

Consent and Policies: 

Informed consent, privacy policy, PIPEDA compliant, cancellation policy, signature. To provide the highest standard of care, we maintain detailed PIPEDA compliant clinical records. We recommend consistent session frequency to ensure optimal results. We kindly ask that you adhere to our cancellation policy and refrain from recording sessions to protect the privacy and integrity of the therapeutic process. 

Confidentiality Agreement: 

All clinical info remains strictly confidential, sacred. Exceptions: risk of harm to yourself or others, insurance provider verification for services rendered, or legal requirements-subpoena. De-identified information ia used for clinical training ongoing certification purposes to ensure the highest quality care; proven evidence based approaches.  

Teletherapy Consent & Risk:

Due to the nature of teletherapy, we remain patient with technology, connectivity, background noise. We work to deliver the full clinical time required. We protect our time prior, post session for therapy processing.Therapy carries risks, we are not making you feel better, but to enlarge your capacity, motivated for growth.

Success Measures:

Therapy is a symbolic space where we acknowledge the need to put self-care first, to lead others. We will identify clear, specific goals that evolve over time. Our therapeutic alliance is a team-based, egalitarian synergy to attain your goals. Honesty is an essential element, be honest with yourself to ensure honesty in therapy. Feedback is highly valued as it elevats your service. Homework in observations, exercises, processing, accelerate your progress.

Thank you for choosing Lee Park, Canada Online Therapy.  

New Client Registration Form