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Client Inquiry Form

In order to better understand specific needs and provide individualized service to our clients, please complete this form
prior to the learner's scheduled assessment.
I am seeking services for:
If for a child, please indicate your relationship:
Please indicate if you are receiving government funding:
Which type of government funding?

*Please note: Adult learners without the legal substituted consent via legal representative will be treated as autonomous.

Intake Questionnaire

Programming incorporates the principles and practices of Applied Behavior Analysis (ABA) in order to improve socially significant behaviour.

To provide individualized services to our clients, please describe the specific therapeutic goals you would like to prioritize at TIPES.

 

Examples of goals include:

  • Behavioural therapy

  • Educational support

  • Caregiver training

  • Social skills

  • Mental health support

  • Challenging behaviour support

  • Systems navigation

Please include specific information about the needs of the individual who will be accessing services.

Please indicate your preferred clinical supervisor.

For most services, a clinical psychologist or Board Certified Behavior Analyst (BCBA) is required to supervise the learner's programming and progress on a monthly or bi-monthly basis.

Currently a client of Dr. Sherman?

Limitations of Confidentiality

Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows: 

Intake Questionnaire

Duty to Warn and Protect 
When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. 

 

Abuse of Children and Vulnerable Adults 
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities. 

 

Prenatal Exposure to Controlled Substances 
Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. 

 

Minors/Guardianship 
Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records. 

 

Insurance Providers (when applicable) 
Insurance companies and other third-party payers are given information that they request regarding services to clients. 

 

Information that may be requested includes, but is not limited to types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries. 

Thanks for submitting!

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