New Client Questionnaire (Adult)

My Therapy Online

Please correct the errors described below.

Hello and Welcome!

I’m very pleased to “meet” you! And I look forward to supporting you towards better sleep. ☺

Please tell me a bit about yourself and your sleep 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 online message at: mytherapyonline

Client Information

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?

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 psychotic experiences
  • If your safety is currently at risk due to domestic violence or other abuse

If you are in crisis, please call the Crisis Line at 1-800-SUICIDE or go straight to the nearest emergency room of your local hospital. In BC, 310-Mental Health: Call toll free 310-6789 (no area code needed) to access emotional support, information and resources specific to mental health and substance use issues - 24 hours a day. 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/

Some possible conditions that may affect having insomnia therapy

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 by sleep experts around the world.

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

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.

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.

How would you like me to contact you?

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 secure web based message system. This is to help protect your privacy. Please add lorraine@mytherapyonline.ca to your contacts to avoid my message ending up in your spam folder.

Please tell me more about your sleep

Bedtime routine

For the following questions, please think about your most recent *typical* week. And specify if and how different on weeknights versus weekends.

Middle of the Night

End of the Night

Sleep / Insomnia History

Medications

Napping

Sleep Environment

Other things that can affect sleep.

Please mention time, frequency, amounts.

Sleep Preferences

Breathing and snoring

Nightmares

Goals

Thank you!

Looking forward to talking to you! :)

Signature

Type your full name

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