Group Intake Process

The Listening Space

Group Intake + Informed Consent / Jude Wong, RPC-C, HCH

This information helps me to get a sense of the people who will be attending this session of The Listening Space. It is collected and stored in a fully encrypted environment, meeting international standards of online privacy. Thank you.

BASIC CONTACT

Name*

First NameLast Name

Preferred contact method *

Email address*

example@example.com

Preferred Phone #*

Area CodePhone Number

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How did you hear about The Listening Space?

Basic Medical

Anything that may affect your participation or require accommodation + how long you have been experiencing this:

Description:

Previous Experiences

Have you participated in therapeutic group(s) before and, if so, how was your experience?

Are there other group experiences you feel are relevant or related and if so, how was your experience?

Please share briefly about any previous experience(s) in counselling or therapy, or with personal growth work you have found useful:

Hopes and Fears

Share a few words about what draws you and what you hope to get out of this experience

Share a few words about what scares you about this experience

Payment

Please indicate how much you would like to pay for these sessions:

One-Time Payment between $160 and $280Deposit + One Payment: $100 upon registration and the rest by October 30, 2023Deposit + Two Payments: $100 upon registration, a 2nd payment on October 30th, and a final payment on November 15th, 2023

And how you would like to pay:

Amount

Should the group be cancelled for reasons beyond the control of the facilitator, full refunds will be issued. Otherwise, all deposits and fees are non-refundable.

INFORMED CONSENT

Informed Consent means that you are aware of the following risks + parametres before engaging in The Listening Space. Thank you

Professional Qualifications + Supervision

Jude Wong has experienced individual and group therapeutic settings for the past decade, including Heart-Centred Hypnotherapy, Way of Council, Systemic Family Constellations, and Compassionate (Non-Violent) Communication, among others, completing both didactic as well as experiential training in these forms.

Jude holds a Diploma in Applied Counselling and Psychology, Specialization in Counselling, and is currently practicing as a Candidate Registered Professional Counsellor, with the Canadian Professional Counsellors Association. She is also certified in Heart-Centred Hypnotherapy with The Wellness Institute, in Washington, USA.

Basic elements of your session(s) may be shared with her supervisor, Ian Gartshore, M.Th., R.C.C. #2560., in order to ensure the best possible outcomes + learning.

If you encounter a concern about Jude's professional competency or conduct while participating in The Listening Space, you are encouraged to first address it directly with her. If this is impossible or unsafe, or if your concern is not resolved through discussion, you may submit a complaint to the Canadian Professional Counsellors Association by visiting https://www.cpca-rpc.ca/disciplinary-procedures~.aspx

I acknowledge and accept the qualifications and supervision of Jude Wong as the facilitator of The Listening Space.*

Yes

Authorization and Privacy with Online Information

By submitting the information in this form, you are authorizing Open Session Space to collect and store your personal and medical information, for the sole purpose of The Listening Space. This information is gathered and stored in a fully encrypted online environment, to international standards of online privacy for personal health information.

I authorize Open Session Space to collect and store my personal information, solely for this session of The Listening Space.*

Yes

Nature + Risks of Participation in The Listening Space

Group Intentions, including confidentiality, self-care, and communication, will be addressed at our first session. Time spent in the group space is usually uplifting, insightful, illuminating, and grounding. However, any kind of dedicated group may at times reflect or evoke challenging patterns of relating with others. You may at times feel some of the difficult emotions that come with these patterns between group sessions. The Listening Space is a supportive environment to explore these difficult emotions, if and as deeply as you feel comfortable and safe to do. Especially in the group space, these experiences are often gateways to learning and growing in the ways we seek most deeply. Jude is also available for consultation, should you feel the need to seek out support.

I acknowledge and accept the nature of group process and the inherent, interim risks of this endeavour.*

Yes

Signature of Informed Consent*

Clear

Date

DateHourMinutesAM/PM Option

Thank you for taking the time to complete this information. Jude looks forward to holding space with you and will contact you soon to schedule a private, 15-20-minute meeting between now and the starting date.