New Client Intake Process

New Client Intake Process

Jude Wong, RPC-C, HCH / Open Session Space

This information covers some of the major areas of your background and current circumstances so we can 'go from there' during your session time. It is collected and stored in a fully encrypted environment, meeting international standards of online privacy, and should take approximately 15-20 minutes to complete. Thank you.
BASIC CONTACT
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Preferred contact method *
Email address*
example@example.com
Preferred Phone #*

Area CodePhone Number
Private messages can be left here for me*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about Jude, Open Session Space?

0/200
EMERGENCY CONTACT

This person needs to be local, especially where online sessions are concerned, and someone who can be made aware of your sessions with me. Thank you.
Name*

First NameLast Name
Relationship to you*
Contact Location*
Contact's Phone*

Area CodePhone Number
This is a*
PERSONAL CONTEXT
How do you identify?*

LGBTQBIPOCIndigenousRefugee or ImmigrantNeurologically DiverseEmpathHighly Sensitive PersonPerson with Exceptionalities (Disabilities)Other (describe below)
Other Social/Cultural Identity
Gender Identity*
Sexual Preference*
Other Sexual Preference
Relationship Status*

SingleDatingLiving with PartnerMarriedRecently Divorced / SeparatedTaking space from a current relationshipOther (describe below)
Other relationship status
Children*
What are their Names, Genders + Ages?*

0/200
How would you describe your current living arrangements?*

I live aloneI live with my child(ren)I live with my partner and child(ren)I live with my parentsI live with roommate(s)I am/We are rentingI/We own a homeI am between homes / couch-surfingOther (describe below)
Other living arrangement
What is your main vocational focus right now?*

Employed full timeEmployed part timeSelf-Employed / Business OwnerIn School or TrainingRecovering from illness or injuryLooking for work / In transitionOther (describe below)
Other vocational focus
Interests, Hobbies + Recreation

0/200
MAIN INQUIRY
What are the primary themes that have brought you to seeking this support?*

RelationshipsLife patterns + directionOverwhelming emotions, low or fluctuating moodTraumatic experience(s)Grief / Loss / BereavementMajor life transitionCompulsive behaviour or addictionPhysical condition (mind-body connection)Other (describe below)
Other theme
How is this affecting you?*
On a scale of one to five, how greatly is this impacting your ability to function effectively (relationships, concentration, eating, sleeping)?
Goals / Inquiry

Briefly describe what you would like to resolve or know more about, as a result of this endeavor, as succinctly as you are able to at this time. This is an invitation to explore, and there are no wrong answers.0/2000
Do you have a spiritual belief that you could describe?

This practice is not associated or affiliated with any religious or spiritual practices; however, when and if there is a spiritual belief, it can be helpful to include or incorporate it. Thank you.0/200
PREVIOUS COUNSELLING + WELLNESS EXPERIENCES
Have you seen a counsellor or therapist before?

YesNo
When and for how long?

0/200
What type of counselling/therapy was this?

0/200
What was the focus of these sessions?

0/200
Outcome / Comments

0/200
Other related experiences?

What are some other things that have helped you to overcome emotional or psychological challenges in the past --- yoga, meditation, journalling, support groups, self-help materials, public programs, spiritual influences, etc.0/200
MEDICAL CONTEXT
Current (acute) physical conditions or injuries

0/200
Chronic Physical or Mental Health Conditions

(Diagnosis where applicable + number of years)0/200
Operations + Hospitalizations

(with year or length of stay)0/200
Birth information you are aware of

(Easy or hard labour? Short or long ... Cesarean or natural ... Breached birth, umbilical chord around the neck, or other conditions and challenges)0/200
Phobias

(Heights, animals, small spaces, etc.)0/200
Allergies

(Animals, scents + other environmental)0/200
History of psychosis, hallucination, or paranoia?

(Age, length + treatment received)0/200
Major traumas and losses + year/age*

(Share what you can easily share here --- Accidents, traumatic losses or other experiences, abuse and violence, etc.)0/200
What has been your relationship with substance addiction?

No history or experience of substance addiction.Mild history, but no formal identification or treatment.Formal history of addiction and treatment.Currently using substances in active addiction.Unsure / questioning my relationship with substance addiction.
Other comments or questions about substance addiction

0/200
Is there anything else you would like to tell me or ask me?

0/200
INFORMED CONSENT

Informed Consent means that you are aware of the following risks + parametres before engaging in sessions with me. Thank you
Professional Qualifications + Supervision

Jude Wong has experienced individual and group healing in a variety of therapeutic settings for the past decade. She holds a Diploma in Applied Counselling and Psychology from the esteemed Kelowna College of Professional Counselling and currently practices in Duncan (Open Session Space), under supervision, as a Registered Professional Counsellor-Candidate with the Canadian Professional Counsellors Association (CPCA).

Jude is also certified, with extensive and immersive experience, in The Way of Council, with the late Ojai Foundation, formerly in Ojai, California and in Heart-Centred Therapies with The Wellness Institute in Washington State, USA, including Heart-Centred Hypnotherapy. She spent many years immersed in Systemic Family Constellations throughout the West Coast with Jan Hull at Coastal Constellations, and carries years of training and practice in the integration of Compassionate (Non-Violent) Communication.

Basic elements of your session(s) may be shared with her supervisor, Andrea Campbell, MA, RPC, MPCC-S, RCC, RSW, #3231, in order to ensure the best possible outcomes and learning.

If you encounter a concern about any aspect of your counselling, you are encouraged to first address it with your counsellor. 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 in the field of professional counselling and integrated therapies.*

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 counseling process. 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 the counseling process.*

Yes
Confidentiality in the Session Space

Confidentiality is essential to the counselling process. Your attendance of sessions and all information shared during sessions is held in the strictest of confidence and will not be shared with any other parties under any circumstances, even after the end of the counseling relationship.

There are, however, three exceptions to this essential agreement. If any of the following were to occur, your counselor would be professionally obligated to engage the appropriate medical or emergency services. He/she would work transparently and CO-CREATIVELY with you to the greatest degree and for the very best outcome possible.

1. Knowledge of Current or Imminent Harm to self, including self-harm and suicide.

2. Knowledge of Current or Imminent Harm to another person, including minors and other vulnerable populations.

3. Court Request for Information. I am also obligated to respond to legal requests for information during legal proceedings, providing only the details specifically requested.
I accept and acknowledge my rights of confidentiality and the exceptions to that right in this process.*

Yes
Nature + Risks of Counselling

Difficult topics, intense emotions, and new perspectives are all part of the counselling process. Sometimes, it may feel like things get worse before they get better, and this is also a very natural part of the process. You set the pace and intensity of your work, however; and no one has ever regretted a healthy counselling process. On the other side of it all is deeper personal awareness, compassion, esteem and empowerment, new ways of understanding and addressing challenges, and improved relationships, with others, yourself, and with life itself.
I acknowledge and accept the nature of the counselling process; the inherent, interim risks of this endeavour; and my own right to set the pace of this work.*

Yes
Personal Safety in Between Sessions

Most sessions result in very positive feelings immediately following; however, from time to time, strong feelings of grief, anger, or other core emotions may arise between appointments.

In the event of an emotional or mental health crisis, Open Session Space / Jude Wong, RPC-C is not able to provide emergency mental health care and would encourage you to contact local emergency services.

To create an additional safe 'container' for intense or overwhelming emotions between sessions, choose one of the following statements:
I affirm that I have at least one friend or family member I am prepared to connect with if I am feeling upset or unsafe
I agree to notify my therapist and schedule a follow-up session as soon as possible if we determine this as the next best action
Other (please describe or comment ... this can be addressed during your first session)
0/200
I agree to the personal safety agreement above, and to contact my local emergency services in the event of an emotional or mental health crisis while undergoing counselling at Open Session Space.*

Yes
Nature + Risks of Heart-Centred Hypnotherapy

Focussing on Negative Emotion: Many people, cultures, and even practices, work from the belief that intense emotions are dangerous or harmful, inappropriate, unevolved, or simply ineffective to focus upon or express. In Heart-Centred Hypnotherapy, we view the core emotions (anger, fear, sorrow, etc) as powerful connectors, through the way they activate the nervous system, creating a "bridge" to the source experiences of this inquiry. Practitioners are trained to support and respond to intense emotional states and have all journeyed, expressed, and received the work themselves.

Safety + Accuracy of Memory Retrieval: At no time during the 35 year history of this work has anyone ever gone to a place or a memory that they were not able to draw inspiration and return safely from. As far as the controversial subject of accuracy, when it comes to memory retrieval, Heart-Centred Hypnotherapy responds to this with the 'inner knowingness' that is also integral to the work. We can know whether or not something is true during this work in a way that is simply inexplicable; we can also know whether or not something is true by the way that this new reality unfolds in ourselves and our lives.
I acknowledge and accept the nature and risks of intense emotion and memory retrieval in Heart-Centred Hypnotherapy, should I choose to pursue this modality at any time during my counselling at Open Session Space.*

Yes
Fees + Cancellation Policy

Session Fees are due at the time of your session and can be received through PayPal or by Email Money Transfer.

Changes or cancellations can be received by text, phone or email. Those received with less than 24 hours notice may still be billed, in full or in part, at the discretion of the practitioner.
I acknowledge and agree to the Fees + Cancellation Policy of Jude Wong, RPC-C at Open Session Space.*

Yes
Online Considerations + Privacy

1. Internet Interruption. If the connection is not restored momentarily, I will make every effort to reconnect and reschedule with you, as soon as possible, with the contact information you have provided.

2. Online Privacy. Because of the nature of the internet, it is not possible to guarantee privacy during online sessions to the degree offered by phone or in-person. This being said, online sessions are standard practice in the profession of counselling, as long as you are made aware of this inherent risk. Online counselling is also mandated and regulated by Canada's Personal Information Protection and Electronic Documents Act (PIPEDA).

3. Working Space. Receiving services online means that you are responsible for securing a quiet, private, and uninterrupted space for your session(s). Please ensure you will not be interrupted as much as is possible, for the duration of your session.

4. In Case of Emergency. Your physical address and cell phone / texting number, where possible, are gathered as a precaution for any medical or environmental emergency that may arise during the session, to which I would otherwise be unable to respond.
I have read and understand the considerations of receiving counselling online, and I accept these terms of engagement, should I choose to pursue online sessions at any time during my counselling at Open Session Space.*

Yes
Signature of Informed Consent*

Clear
Date

YearMonthDay
DateHourMinutesAM/PM Option
Thank you for taking the time to complete this information. If you have not already done so, you may now book your first session by emailing Jude -- in Nanaimo here, or in Duncan here.

Return to www.sessionspace.ca.
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