EMHware :: Resolve Counselling Services Canada

Please note, some of the questions below are used for data collection purposes only and responses are optional. By submitting your answer, you acknowledge and agree that the content may be stored, analyzed, and used to improve services, conduct research, or generate insights. No personally identifiable information will be collected or shared without your explicit consent.

First Name:

Last Name:

DOB:

	Company:
	Relationship to Employee (employee, spouse, dependent):

Are you completing this form on behalf of another individual or a child or dependent under 16?

Yes

No

If yes, do they consent to you sharing this information?

Yes

No

Gender:

Sexual Orientation:

Pronouns:

Address:

City:

Province:

Postal Code:

Primary Phone:

Alternate Phone:

Email:

Permission to contact via phone:

Permission to leave a message:

Permission to contact via e-mail:

If you would like to receive appointment reminders, please indicate preference:

Preferred Language:

If mother tongue is neither French nor English, in which of Canada's official languages is the client most comfortable?

English

Freanch

Do you require an interpreter to access services?

Highest Level of Education:

Employment Status:

Source of Income:

Net Monthly Household Income Range:

$1200 and under

$1201 to $1600

$1600 to $2400

$2401 to $3000

$3000 and over

Do you have access to insurance or extended health benefits?

Indigenous Status:

Band/Status # (optional):

This information is collected to determine eligibility for counselling covered by Non-Insured Health Benefits.

Citizenship Status:

Primary Ethnicity/Cultural Identity

Country of Origin

	How did you hear about Resolve?
	Type of Service
	Referral Source:
	Reason(s) for the referral:
	Do you require accommodations for accessibility?
	If yes, please describe:
	Are you currently accessing counselling services elsewhere?
	If yes, where and what type:
	Have you accessed our services previously, yes or no?
	How would you prefer to receive counselling services?
	Are you currently accessing any other mental health supports?
	If yes, please describe
	If you are interested in accessing groups, please specify which type of group you are looking for

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. Resolve Counselling will take whatever steps necessary to avert danger to a client or others.  The threat of harm will always take priority over confidentiality.  Resolve Counselling has adopted this policy for the welfare of our clients, staff and the community at large.

Understanding Limits of Confidentiality
	Yes, I understand the limits of confidentiality.

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 Resolve Counselling.

I understand that pressing submit will forward this information to the intake department.

Yes, I consent to services.

Upon submitting this form, you will be contacted by intake to complete the next steps.

Please note, Resolve Counselling Services Canada is not a crisis service. If you are experiencing a mental health crisis, please contact the Addictions and Mental Health Services (AMHS) 24/7 Crisis Line at 613-549-4229. If you are in immediate danger or experiencing an emergency, please call 911 or visit your nearest emergency department.