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Life is a journey, and we sometimes need someone to walk with us while we are feeling low. Sometimes, we fall, and we need someone to lift us up on our feet. You are not alone. Let’s take that walk with you and harness your Joy.

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New Client Intake & Consent Form

Welcome! Please complete this form before your first session. Your information is confidential and used solely for the purpose of providing counseling services.

Personal Information

Full Name

Phone Number

Email Address

Address

Emergency Contact Name & Phone

Insurance Information (Optional)

If you would like us to submit claims on your behalf through direct billing, please provide the following:

Insurance Provider

Policy / Group Number

Member ID / Certificate Number

I consent to the use and disclosure of my insurance information for the purpose of direct billing.

By checking this box, I give permission for Harness of Joy to submit claims to my extended health insurance provider on my behalf. I understand that I am responsible for any portion not covered by my insurance plan.

Consent to Counseling Services

I understand that the counseling services provided by [Your Name], Registered Social Worker, are confidential, with the exception of limits to confidentiality as required by law (e.g., risk of harm to self or others, child protection concerns, or if records are subpoenaed by court).

I understand that I may withdraw from counseling at any time.

I agree to attend scheduled sessions or provide 24 hours’ notice for cancellations. I understand that missed appointments without adequate notice may be subject to a cancellation fee.

I understand that personal information will be collected, stored, and used in compliance with applicable privacy legislation (e.g., PHIPA, PIPEDA).

I consent to receiving counseling services from Omen Imoisili, RSW.

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Date

I confirm that all information provided is accurate and complete to the best of my knowledge.

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Harness of Joy
Psychotherapy Services INC.

If you are in crisis or distress and in need of immediate support, please call a local crisis line at 1-800-784-2433 (1-800-SUICIDE) or 310-6789 for emotional support. Please call 911 in case of an emergency.

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New Client Intake & Consent Form

Personal Information

Insurance Information (Optional)

Consent to Counseling Services

Signature

Address List

Links List

Harness of Joy
Psychotherapy Services INC.