Initial Questionnaire & Therapy Contract

Adults

Thank you for being here - as a first step, please complete all sections below and submit.
All information is kept strictly confidential.

Part 1 — Initial Questionnaire

Personal Information

Reason for Seeking Therapy

General Mental Health

Substance Use

Support System

Goals for Therapy

Part 2 — Therapy Contract

1. Introduction

Welcome to my practice. This contract outlines the terms and conditions of our therapeutic relationship.

2. Psychotherapist's Responsibilities and Limitations

As your therapist, I am committed to offering professional, ethical, and confidential therapy. My role is to provide professional support, address mental health challenges, and facilitate personal growth. Please note:

  • I do not provide emergency services. In case of an emergency, please visit the nearest hospital.
  • I do not prescribe medication. I can refer you to a medical professional if needed.
  • If your needs are outside my expertise, I will refer you to a specialist.

3. Client Confidentiality

All personal details, session discussions, and records are kept confidential, except in the following circumstances:

  • If you disclose an intent to harm yourself or others, I am legally obligated to take action to ensure safety.
  • If there is suspicion or evidence of abuse or neglect involving a minor, elderly person, or vulnerable adult, I am required by law to report it.

I cannot provide statements for court procedures unless legally required.

4. Substance Use Policy

Please do not attend sessions under the influence of alcohol or drugs.

5. Payment and Cancellation Policy

  • Pre-payment is required to confirm each session.
  • Please give at least 24 hours' notice to cancel or reschedule. Cancellations within 24 hours, or no-shows, will be charged the full session fee.
  • Each session lasts 50 minutes. A 1.5-hour session can be booked depending on availability.

6. Discontinuing Therapy

You are free to end therapy at any time. It is advisable to discuss this and consider a final session for closure.

Looking forward to meeting with you.