Our organisation has taken this initiative for total social service purpose. Before your first counseling session, it is important that you have an idea of the guidelines around confidentiality. The personal information that you discuss is held in strict confidentiality, with the following exceptions:

1) If there is required to report to the appropriate child welfare authority (i.e., Children’s Aid Society, Catholic Children’s Aid Society, Jewish Child & Family Service, or Native Child & Family Services) and/or other relevant authorities if I have a reasonable suspicion that a child (ren) may be in danger of harm and/or abuse.

2) In cases where your initial individual appointment is in order to determine the accurate therapeutic process, information provided on this form may not be kept confidential.

3) If we are obliged to notify the proper authorities if I have a “reasonable suspicion” that a client may harm himself or herself or the other parent.

4) If there required by law to release records if they are subpoenaed by court order,

5) If you are a minor, parental consent is required for a therapist to meet with you. Conditions of confidentiality are negotiated with you and your parent/ guardian.

6) If you are attending for marital therapy any information provided, at the therapist’s discretion, may be shared with your spouse or partner.

7) For Family Therapy, the parents recognize the need for themselves and/or minor child to enter into a counseling relationship. Each understands that counseling will be most effective if each party feels free to discuss information that they may not otherwise wish to be privy to others, including any or all legal arenas. For this reason they have agreed not to subpoena or otherwise share any information that was obtained through this process without the express written permission of the other parent. The parents further recognize that there is no confidentiality between each of the parties but that the therapist has discretion with regard to minor children, given that information shared by the therapist may place the child (ren) in an uncomfortable position.

8) There may be times when it is important to consult with other professional connected with you and your family, such as a physician or teacher or lawyer. No such consultation will occur without a specific reason or without your written consent.

9) Information may be used for educational, consultative or supervision purposes. This would not involve disclosures of identifying information.

10) Please request a copy of my Privacy Policy at info@marssk.org, for further information on storage and retrieval of your confidential information.

THE COUNSELLING RELATIONSHIP: The counseling relationship is centered on the needs of you, the client. You are encouraged to let me know if you have any concerns or dissatisfaction with the process. We will welcome any feedback that you may have.

Give us the following details

Name:

DOB:

Address *

Phone Number *

Email ID *

Relationship status:

Married
Single
Separated
Divorced
Widowed
Engaged

Are you seeking counseling with/for someone else?

Yes
No

If yes, specify:

Emergency contact

Name

Mobile

Your reasons for seeking counseling?

Your hopes to see changes as a result of counseling

Declaration: I hereby declare that I have read and understood above terms and conditions and will adhere to it*