INTAKE FORM

Mother Daughter Empower Counselling + Coaching Intake Form:

Please take a moment to fill out this form before your first session.

If you have any questions, please e-mail us at: hello@motherdaughterempower.org

Client Name

First Name

Last Name

Pronouns

DOB

YYYY

Parent or Guardian Name

First Name

Last Name

RELATIONSHIP TO YOUTH:

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Ethnicity

Religion

SCHOOL NAME

School Grade

Please check off the topics that you would like to focus on:

FAMILY & RELATIONSHIPS

FRIENDS & RELATIONSHIPS

SCHOOL/ CAREER

PHYSICAL HEALTH & WELLNESS

MENTAL HEALTH & WELLNESS

PERSONAL DEVELOPMENT + CONFIDENCE BUILDING

ANXIETY & STRESS MANAGEMENT

PAST TRAMA

OTHER

"OTHER" TOPICS PLEASE LIST THEM HERE:

PLEASE LIST YOUR STRENGTHS

please list at least X3 things that you are really good at!

PLEASE LIST YOUR WEAKNESSES

Please list 1-3 areas that you can work on

Please tell us the reason for booking this session:

What would you like to accomplish during this session + what is X1 area that you would like to focus on:

Parent/ Guardian-> this is your opportunity to help us understand your child's needs so that we can set appropriate goals during each session.

Is there anything else you would like us to know:

PLEASE REVIEW MOTHER DAUGHTER EMPOWER'S CONFIDENTIALITY POLICY STATEMENT FOR COUNSELLING & COACHING SERVICES

Everything that is brought up in any of Mother Daughter Empower's counselling & coaching sessions will remain confidential. With your permission, we will collect non-identifying information during our intake to our funders for services and needs analysis. At Mother Daughter Empower, only those needing access to your file will have access to it. We will not contact other people to get information about you or your family without written permission. Information about you or your family shall only be disclosed when authorized by you or your representation, through a signed consent, or when we are legally obligated to do so. All situations other than those presented in our exceptions and limits to confidentiality form must be authorized by you, through your signed consent. You decide to whom we can speak, and what we can disclose to them, using the Consent to Release Information Form. EXCEPTION & LIMITS TO CONFIDENTIALITY: 1. When any type of child abuse/neglect allegations (current or historic) are disclosed, or if we suspect a child might be at risk of abuse, we are bound by law to report these matters to the Children's Aid Society; 2. When allegations of sexual abuse by a health professional have been disclosed; 3. When someone's safety is at risk (suicide/homicide/threats of harm towards self or others), we may break confidentiality (i.e call the emergency contact we have on file, call the police and /or warn the person who may be at risk); 4. During some legal proceedings, your file and this organizations worker may be called to Court. Similarly during an inquest, when served with a subpoena or search warrant, police or other officials may have access to your file; 5. In divorce situations, the access parent may have the ability to access your child's file through a Court Order; 6. For purposes of individual or team supervision, agency accreditation, quality assurance reviews, Ministry reviews where applicable, the content of your file may be reviewed and audited.

I HAVE READ AND AGREE TO THE ABOVE CONFIDENTIALITY POLICY STATEMENT

Please provide us with 24 H notice if you need to cancel and or reschedule your appointment. Mother Daughter Empower will terminate your coaching & or counselling term if more than one appointment is missed without notice.

PLEASE SIGN HERE

TYPE IN YOUR NAME AS SIGNATURE

INTAKE FORM

Mother Daughter Empower Counselling + Coaching Intake Form:

What we do

Discover

need help ?

get involved

Stay connected

mother daughter

empower