New Client Questionnaire (Adult)

Emergency Assistance

If this is an emergency, please go to your local hospital emergency department right away or call:

Crisis Line: 1-800-SUICIDE
9-1-1

Hello and Welcome!

I’m very pleased to “meet” you! I look forward to supporting you and helping you find ways to live the life you’re longing for. My dream for you is that it meets all your hopes and expectations. ☺

Please tell me a bit about yourself before we get started. And do feel free to give me a call at 604-771-4444 if you have any questions or concerns about any of this! Or send me a secure message at: https://hushforms.com/lorraine412

Client Information

First name

Last name

Home phone number

Cell phone [if no cell, please list landline again]

Date of birth

Email address

Are You 19 Years Old or Older?

Yes No

If not, I’m terribly sorry to let you know that I’m not currently able to offer this service. Please check with your doctor or school counsellor (if you have one) for ideas for other possible resources. Or let me know if you need some ideas of where to look.

Are you residing in Canada?

Unfortunately, regulations only allow me to provide services in Canada

Yes No

Are you in crisis?

For many people, the benefits of online counselling make it a perfect fit. But it is not suitable for everyone. For some situations, Internet counselling is not appropriate and you’d be better served by face-to-face counselling or other crisis resources. For example:

If you are feeling suicidal or dealing with severe mental health issues
If you are coping with bi-polar disorder or psychotic experiences
If your safety is currently at risk due to domestic violence or other abuse

Please see above right hand column for crisis resources. You might also want to speak to your doctor about possible resources and referrals in your area. Other crisis resources may be found at: http://mytherapyonline.ca/possible-drawbacks/

Please check this box to confirm that none of the above situations apply to you.

Are you interested in help for insomnia?

The great news is that Cognitive Behaviour Therapy for Insomnia [CBT-I] has been shown in research to be wonderfully effective at reducing insomnia and improving quality of sleep for many people! That's why it's considered the #1 recommended treatment.

However, there are a few conditions or circumstances where it is not suitable - and some where we might need to modify the CBT-I approach. To help reduce the chance of you investing time and money into beginning this therapy if it might turn out to not be the best fit for you right now, let's go over some of the more common contraindications and obstacles to effective CBT-I. If you're not sure how any of this might apply to you, or have any questions, or just want to discuss the possibilities, please feel free to give me a call at 604-771-4444. Or send me a secure message via: https://hushforms.com/lorraine412

Have you ever been diagnosed with or do you think you may have any of the following?

Circadian Rhythm Sleep Disorder

If you don't have a severe diagnosis, we might still be able to proceed with CBT-I. Please contact me to discuss.

Shift Work Disorder

Depending on your situation, we might be able to proceed with CBT-I. Please contact me to discuss.

Nightmare Disorder

Note: This is NOT the same thing as having nightmares. If you have nightmares, but have not been diagnosed with Nightmare Disorder, please contact me to discuss whether you might still be eligible for CBT-I and help reducing nightmares

Uncontrolled Seizure Disorder

Note: I may be offering a modified CBT-I in the near future. Let me know if you're interested.

Bipolar Disorder

Note: I may be offering a modified CBT-I in the near future. Let me know if you're interested.

Current Active Alcohol and Drug Use Disorder

Unfortunately, you may not be able to benefit from CBT-I because drug and alcohol use can insomnia and poor sleep quality.

PTSD

It's possible that you may benefit from first receiving treatment for PTSD before beginning CBT-I. Please contact me to discuss.

Untreated Sleep Apnea

If you're sleep apnea is currently being successfully treated [e.g. with CPAP], we can likely go ahead with CBT-I.

Fees

Unless otherwise agreed, fees, including all applicable taxes, are $120.00 Canadian per 50 minute session or $144 per 60 minute session, and are pro-rated at $2.40 per minute for shorter or longer sessions if applicable [as per Recommended Fee Schedule of BC Association of Clinical Counsellors].

If you are unable to afford the regular fee, I do my best to offer a sliding scale, when possible.

Would you like to request a reduced sliding scale rate?

Yes No

If yes, please tell me a little about your financial circumstances and how much you can afford.

If you have an extended health plan: Many employers provide coverage for the services of a Registered Clinical Counsellor (RCC). This is between you and your extended health plan, so you may wish to confirm with them that they cover these services from a Registered Clinical Counsellor, as you’ll need to pay for the counselling session yourself and then request reimbursement from them.

Please let me know if you would like an official receipt for this purpose.

Yes No

How would you like me to contact you?

Phone #

E-mail [*Please double check accuracy!]

Please note that when I reply to an email, you'll receive a message telling you to click on a link that takes you to a web based message system. Please add lorraine@mytherapyonline.ca to your contacts to avoid my message ending up in your spam folder.

Is it okay for me to leave a voice message if you don't answer when/if I call?

Yes No

One last question

How did you hear about this service?

Thank you!

Looking forward to talking to you! :)

Signature

Signed

Type your full name

Today's date

Your message will be encrypted and can only be read by Lorraine Irlam, M.A., RCC.

New Client Questionnaire (Adult)

Emergency Assistance

Hello and Welcome!

Client Information

Are you residing in Canada?

Are you in crisis?

Are you interested in help for insomnia?

Fees

How would you like me to contact you?

One last question

Thank you!

Signature

Emergency Assistance

Lorraine Irlam, M.A., RCC

Registered Clinical Counsellor, My Therapy Online