Drop-in Counselling Sessions - Five Star Relationships

Agreement Form – Community Living Guelph Wellington

This form is for CLGW-connected employees and people supported seeking drop-in counselling support.

Step 1 of 2

Please complete the following information to help your therapist/coach arrange your Drop-in Counselling session. Your information is hosted and stored by Five Star Relationships. Your privacy is our priority and your information will not be shared for any reasons other than to arrange and fulfill your request for a Drop-in Counselling session.
Name*
First Last
Your personal phone*
Your personal email*
Your Home Address*
Street Address Address Line 2 City Province Postal Code
1. Sessions last approximately 45 minutes.
2. If an emergency arises, please go to the emergency department of your local hospital for assistance or phone the crisis line at 1-877-825-9011.
3. If you need to change or cancel an appointment time please give notice at least 24-48 hours.
4. All information shared with your counsellor is confidential and subject to rules regarding privileged communication between counsellor and client. A counsellor reserves the right to consult with other professional counsellors, including a clinical supervisor. However, every attempt will be made to maintain your confidentiality, typically using first names only. Apart from this consultation no information will be shared without your expressed, written and signed consent. Exceptions to confidentiality as required by law, are listed below: i) Where there are child protection concerns ii) Where there is risk of harm to self or others iii) Information subpoenaed by a court
5. In general, I will follow, to the best of my ability, all provincial law and regulations, as well as the policies and code of ethics of the College of Registered Psychotherapists of Ontario
Consent*
I agree and consent to the Client Therapist Agreement Form