Beaumont Clinic Intake Forms - Family Counselling Centres

Client Information - Step 1 of 9
*Please fill out this information form as carefully and thoroughly as possible. The information you provide is protected as confidential information and will be placed into your child’s client file.
Service Agreement
Family Counselling Centres is a private mental health facility, we are not partnered or covered by Alberta Health Services. As such, there is nothing required from your doctor to set up an appointment. If you'd like to request an intake appointment, we do ask for a few more details so we can better match you with a clinician to suit your needs, schedule and billing requirements. Please submit this information to our administrators by completing the following form submission.
Our rate for services is in line with the fee schedule set by the Psychologists' Association of Alberta - office services are $200/HR. We do offer a sliding fee scale for those without insurance coverage.
If you'd like to request an intake appointment, we do ask for a few more details so we can better match you with a clinician to suit your needs, schedule and billing requirements. Please submit this information to our administrators by completing the following form submission.
I understand that by completing the following form submission, that I am seeking services outside of the AHS network. As such, I understand that I assume payment responsibilities for future services rendered once meeting with a service provider *
Yes, I am in agreement and wish to proceed with initiating services.
Service Disclaimer
Family Counselling Centres recognizes these are times of uncertainty for many, at this time we welcome clients to the office for in-person sessions so long as your household is in good health. We will continue to offer virtual sessions for those who are not comfortable coming in, or those feeling ill on the day of their scheduled appointments.
We understand not all clients are comfortable to attend an in-person appointment. Please indicate your preference for sessions: *
I/we prefer in-person sessions.
I/we prefer to be seen by video/telephone.
All clients must be prepared that sessions may have to be switched over to remote service delivery {by telephone or video} in the event of mandatory office closure or Client/Clinician illness.
Preferred Location:
Beaumont Office
Edmonton Office
Leduc Office
We have three office locations to provide you with psychological services. Please select your ideal location(s).
Allergy Disclaimer - WORKING ANIMALS ONSITE
Family Counselling Centres has full-time therapeutic animals working in our office, it is likely you will encounter them while in our communal client spaces.
We are unable to guarantee an allergy free environment at our Leduc location *
I/we prefer to be scheduled WITH animals when possible.
I/we prefer to be scheduled WITHOUT animals when possible.
If you are concerned about the presence of our animal assistants, we encourage you to explore our alternative delivery methods for therapeutic services. *Clients engaging in therapeutic services assisted by animals will be required to complete additional Consent/Liability documents.
Payment Responsibilities
While we are not covered by Alberta Health Services, you may find you have Psychological Service coverage through your employer or third party insurance company.
Are you looking to utilize coverage through a third-party or your employer?
Yes, I have coverage available to utilize
No, I am without extended coverage
*NOTE: Our Student Therapists / Mental Health Therapists are not eligible for coverage under most insurance plans.
Are you looking to utilize our Direct Billing services?
Yes
No
Those without coverage to utilize, who have a gross household income under $140,000 qualify for our sliding fee scale. Are you willing to submit tax documents to prove your income and qualify for this scale?
Yes
No
Please select your extended health provider: *
Direct billing is available ONLY to those insurers listed in the drop-down menu.
Client Information
Please know that all information submitted in this document is held in confidence with our administrators and may be shared with your clinician once services commence.
Is this appointment for yourself, someone else? *
Myself
My child
Myself and my spouse
Please know that clients over the age of majority {18} must contact us to set up their own appointments.
Due to safety concerns, relationship support is only available to those who are NOT presently abusing alcohol, chemical substances, prescriptions or those engaging in risky behaviours in an addictive manner. Failure to disclose this information prior to your appointment can result in the immediate termination of treatment. (copy) *
I acknowledge that neither myself, nor my partner, are presently engaging in addictive behaviours.
Therapeutic Services can only be commenced by a child's LEGAL GUARDIANS. *
I am a biological parent, and will provide contact information for the other parent;
I am a biological parent, and will provide legal documentation to support SOLE-medical decision making;
I am a legal guardian, and will provide legal documentation to support medical decision making;
I am the sole biological parent, widowed.
Which parent passed? *
Date of passing *
(YYYY/MM/DD)
We always begin individual services with a Parent Intake appointment. We ask that adults only attend this appointment, allowing you the opportunity to speak candidly with your clinician about the concerns that bring you to the office, family history and goals for treatment. The clinician also explains their role in the therapeutic process and can explain any questions that come up between now and then.
Client's Legal Name *
First
Last
Preferred Name
Client's Date of Birth *
(YYYY/MM/DD)
Gender Identification *
Male
Female
Non-Binary
Transgender
Intersex
I prefer not to say
Preferred Pronouns
Client's Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Your Email *
Email
Confirm Email
The Intake Coordinator will contact you at the e-mail address provided above once your information is received and an appointment is available and being held for you.
Best Contact Number *
Preferred method of contact? *
Email
Telephone
Can we leave a voicemail for you at the number provided above? *
Yes
No
We always begin multi participant therapeutic services with an Intake appointment including both parties.
Partner's Legal Name *
First
Last
Partner's Date of Birth *
(YYYY/MM/DD)
Partner's Gender Identification *
Male
Female
Non-Binary
Transgender
Intersex
I prefer not to say
Partner's Preferred Pronouns
Partner's Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Partner's Email *
Email
Confirm Email
Your Marital Status (Check one of the following) *
Married
Common Law
Separated
Divorced
Engaged
Complicated
Please explain: *
Caregiver A's Legal Name *
First
Last
*Psychological Services can only be commenced by a child's LEGAL GUARDIAN.
Relationship to Client? *
Mother
Father
Other
Explain Relationship: *
Does the Client live with Caregiver A? *
Yes, Full-time
Yes, Part-time
No, Visitation Only
No
Caregiver A's Email *
Email
Confirm Email
Best Contact Number: *
Preferred method of contact? *
Email
Telephone
Can we leave a voicemail for you at the number provided above? *
Yes
No
Marital Status between Caregivers: *
Married
Common Law
Separated
Divorced
Engaged
Widowed
Caregiver B's Legal Name *
First
Last
*Please ensure you are providing us with the contact information of your child's secondary LEGAL GUARDIAN.
Relationship to Client? *
Mother
Father
Other
Explain Relationship: *
Does the Client live with Caregiver B? *
Yes, Full-time
Yes, Part-time
No, Visitation Only
No
Caregiver B's Email *
Email
Confirm Email
Best Contact Number: *
Tell us more about your needs...
Indicating what concerns bring you to the office help us to match you with a service provider.
I'm looking for support with... *
Anxiety
ADHD
Behavioural Issues
Chronic Pain
Depression
Developmental Disorders
Domestic Abuse / Violence
Grief
Impulse Control
Parenting
Peer Relationships
Pregnancy, Prenatal, Postpartum
Relationship {Individual}
Relationship {Family Conflict}
Self Esteem
Sexual Health
Self-Harm / Suicidal Ideation
Trauma
Addictions {Drug / Alcohol} *WE ARE NOT PRESENTLY SUPPORTING THIS CONCERN.
Date of Last Use *
(YYYY/MM/DD)
We're looking for support with... *
Communication
Parenting
Addictions {Drug / Alcohol} *WE ARE NOT PRESENTLY SUPPORTING THIS CONCERN.
Connection
Depression
Grief
Intimacy
Infidelity
Pregnancy, Prenatal, Postpartum
Relationship {Martial}
Relationship {Family Conflict}
Separation / Divorce
Sexual Health
Date of Last Use *
(YYYY/MM/DD)
Does you/your family have a history of mental illness? *
Yes
No
If yes, please explain:
I'm interested in Animal-Assisted Therapy
Canine Assisted Sessions
Equine Assisted Sessions
Please know Equine-Assisted sessions are NOT available on weekends {late afternoon sessions are limited in winter months due to reduced daylight hours}.
I'm available for appointments... *
Weekdays
Weekends *Not applicable for equine sessions
Daytime {before 3:00PM}
Late Afternoon {after 3:00PM}
Evening {after 6:00PM} *Not applicable for equine sessions
At this time our clinicians are limited for late-afternoon and evening appointments; your flexibility for scheduling will allow for a sooner intake appointment.
I'm interested in scheduling with ...
Agnes Olszewska, Registered Psychologist, Registered Play Therapist {Children, Teens, Adults, Couples}
Amanda Montey, Registered Provisional Psychologist {Children, Teens, Adults}
Cierra Chmiliar, Registered Psychologist, Registered Play Therapist {Children, Teens, Adults, Equine-Assisted Sessions}
Dani-Lyn Neufeld, Registered Psychologist {Children, Teens, Adults, Equine-Assisted Sessions}
Erika Wilcox, Registered Provisional Psychologist {Children & Adults}
Kristianna Podlosky, Registered Provisional Psychologist {Children, Teens, Young Adults}
Shannon Blais, Registered Provisional Psychologist {Children, Teens, Adults - Online Only}
Katie Gruszecki, Registered Provisional Psychologist {Children, Teens, Adults}
Kayla Lucas, Registered Psychologist {Children, Teens, Adults}
Appointment availability differs with each service provider. Not all providers treat all client concerns. https://familycounsellingcentres.com/leduc-team/
Additional notes about your request / availability...
You've selected a preference for services with our intern(s)/MHT, please explain a little more about the support you are seeking to determine suitability {*details are not required}: *
Is there anything you would like us to know before the first appointment?
Signed By: *
Email

Douglas Nechio

Registered Psychologist

douglas@familycounsellingcentres.com

Office: Edmonton and Beaumont

Mr. Nechio has worked in mental health and educational settings providing psychological assessment and therapeutic services. Mr. Nechio has worked collaboratively with various educators, mental health professionals, and families to deliver evidence-based, client centered, psychological services to school-age children and adults both in Alberta and abroad. Mr. Nechio has also been recognized by the provincial court of Alberta as an expert witness in parenting capacity and child psychology legal matters.

Amanda Baird

Registered Psychologist

Office: Edmonton & Beaumont

amanda@familycounsellingcentres.com

I am a Registered Psychologist with the College of Alberta Psychologists, and am trained in the fields of Clinical and Forensic Psychology. I am excited to provide services in the areas of Clinical and Forensic psychology with adults, adolescents and families in both English and French. My main interests and areas of practice include psychotherapy, with an emotion focused approach, with adolescent and adult populations, assessments and consultation. I am also equipped to service those clients with more complex symptomology and/or a more complex presentation.

Regardless of the forum, my ultimate goal is always to provide my clients with the utmost quality help and services by helping individuals and their families navigate through troubling times in their life (including those of a legal nature), in a comfortable and supportive environment. Throughout my 13 years working in the mental health field, 5 of which have been in the role of a Registered Psychologist, I have learned that the process of therapy is as unique as the people who choose to take this brave journey into themselves. Challenges and difficulties are a reality of life, and my role is to guide you toward answering the “now what” question with the goal of obtaining peace and well-being.

BEAUMONT CLINIC FORMS

Appointment Request *Adult

Appointment Request *Child

Appointment Request *Couple

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Service Agreement

Service Disclaimer

Allergy Disclaimer - WORKING ANIMALS ONSITE

Payment Responsibilities

Client Information

Tell us more about your needs...