New Client Screener

Welcome to the Ottawa Institute of Cognitive Behavioural Therapy!

This brief screener is used for competency-based matching. This is intended to identify your therapy goals, needs, and preferences in order to pair you with the most suitable therapist and/or program(s) tailored to you.

Please note: This form is intended for completion solely by the client, unless you are a parent or guardian of a client under the age of 18. For more information about our clinic or services, please visit our website or contact our administrative team at 613-820-9931; ext. 0.

Contact Information

Full Name

Age

Date of Birth

If we need to contact you for follow up, what is your preferred contact method?

Email Phone No preference (email or phone)

Best phone number to contact you:

Please note that our calls will come from a blocked number. Please ensure your phone settings are set to allow such calls.

If we are unable to reach you, may we leave a voicemail at the number provided?

Yes No

Email address

Please keep an eye on your inbox, including your Junk/Spam folder, for the two weeks following submission of this form.

Address Line 1

e.g., 1234 Main St

Address Line 2

e.g., Unit 2A

City

Postal Code

Please note: Our services are limited to certain provinces based on provincial regulations. Please visit our website for more details.

Requested Service

If you have selected more than one service above, please identify which one you are interested in completing first:

INDIVIDUAL THERAPY FOLLOW-UP QUESTIONS

Do you have any therapist preferences? (e.g., type of professional, gender, identities, age range, language)

Yes No

If yes please specify

(e.g., type of professional, gender, identities, age range, language)

Please indicate:

In-person therapy Virtual therapy No preference / whichever is available first

Are you open to virtual therapy if there are no in-person sessions available?

Yes No

Are you willing to work with a PhD Level Practicum student or Resident directly supervised by a Clinical Psychologist? Please note: a practicum student or resident refers to an individual completing their PhD level therapy training in Clinical Psychology. All students and residents have experience providing therapy (e.g, residents have at least 5yrs of experience). All students and residents are closely supervised by a Clinical Psychologist that reviews their sessions and provides guidance. Sessions are at a reduced fee relative to other therapists at OICBT.

Yes No

COUPLES THERAPY FOLLOW-UP QUESTIONS

Do BOTH partners consent to couples therapy?

Yes No

Do you have goals related to domestic violence? (e.g., physical, sexual, financial, emotional, psychological, coercive control)

Yes No

COUPLES THERAPY: PARTNER'S CONTACT INFORMATION

Full Name

Age

Date of Birth

Best phone number to contact partner:

Please note that our calls will come from a blocked number. Please ensure your phone settings are set to allow such calls.

If we are unable to reach partner, may we leave a voicemail at the number provided?

Yes No

Email address

Please keep an eye on your inbox, including your Junk/Spam folder, for the two weeks following submission of this form.

Same home address as above?

Yes - same address No - different address

Address Line 1

e.g., 1234 Main St

Address Line 2

e.g., Unit 2A

City

Postal Code

DBT PROGRAM FOLLOW-UP QUESTIONS

Are you open to both group and individual therapy? Please note: Both are required for the DBT Program

Yes No

Do you currently have a DBT therapist?

No Yes - within OICBT Yes - external therapist

Name of Therapist:

If seeking DBT Stage Two, have you completed a course of Standard DBT (with 3 modules: emotion regulation, distress tolerance, and interpersonal effectiveness)?

Yes No Not applicable (seeking Standard DBT)

GROUP PROGRAM FOLLOW-UP QUESTIONS

Do you currently consume alcohol or drugs 4 or more days per week, or in a way that causes you problems, or in a way which others view as problematic?

Yes No

Any Self-Harm behaviours?

Yes No

How frequently do you engage in self-harm?

Infrequently and/or less than once a month

Monthly

Weekly

Daily

What form of self-harm?

Cutting

Burning

Punching/hitting

Pulling out hair

Breaking bones

Bruising

If yes to any of the above, are you willing to have group + individual therapy (individual therapy to work on above goals)?

Yes No

ASSESSMENT FOLLOW-UP QUESTIONS

Do you have a diagnosis of Autism Spectrum Disorder or suspected ASD?

Yes No

Please provide additional details:

Have you ever experienced a traumatic brain injury?

Yes No

Was was the severity level? If multiple, please indicate the highest

Mild Moderate Severe

Are you still experiencing related symptoms?

Yes No

Please provide additional details:

Have you had a concussion before?

Yes No

When did the concussion(s) occur?

Was was the severity level? If multiple, please indicate the highest

Mild Moderate Severe

Are you still experiencing related symptoms?

Yes No

Please provide additional details:

Clinical Information

If you are unsure about your treatment focus, we will call you to obtain additional information.

Please elaborate - in your words, what are you looking to focus on?

Please elaborate - what is the medical condition you are looking to focus on managing?

Please explain the current impact this has on your daily functioning?

What are the current goals you have regarding this medical condition?

Please elaborate regarding the nature of the addiction:

Please provide additional information regarding the nature of the eating concern(s):

Please provide additional information regarding the sleep issues:

Please provide additional information regarding your maternal health concerns:

Have you been diagnosed with a mental health condition or have a suspected diagnosis?

Yes No

Please select which applies:

Formal diagnosis by a health professional Suspected diagnosis (not formally diagnosed)

Please specify diagnosis and when this was received:

Have you received therapy in the past for these aims?

Yes No

What was the type, length, timing? Were the services helpful?

Are you currently involved in a court case?

No Yes - as the Defendant Yes - as the Plaintiff

Please specify the circumstances of charges:

Are you experiencing any acute crisis situation where there is risk to your life or someone else’s (currently or in the past 3 months)?

Yes No

If yes, please describe circumstances:

Please note we do not provide crisis interventions. If you or someone you know are at risk of harming yourself, please contact your local authorities or present yourself to hospital. The national crisis suicide line can used 24 hours a day by dialling 988.

Have you ever heard, seen or experienced things with your senses that others could not or had strong beliefs that others that were odd or unusual (e.g., others reading your mind, receiving special messages, others plotting against, having atypical talents, having a special mission, etc.)

Yes No

If yes, please describe circumstances and date of last occurrence:

Do you experience/been diagnosed with any neurological disorders? (e.g., dementia, essential tremor; Alzheimer's disease. Parkinson's disease. Huntington's disease., prion disease.,multiple sclerosis, hydrocephalus, etc.)

Yes No

If yes, please describe circumstances and date of last occurrence:

Have you ever experienced an abnormal and excessively elevated mood (e.g., feeling euphoric, very hyper, excitable, or high) or excessively irritable mood that lasted most of the day for several days in a row?

Yes No

If yes, please describe circumstances and date of last occurrence:

Please indicate if you experience 4 or more of the following: Recurring challenges with close relationships; chronic suicidal thoughts and/or self-harm; impulsivity in at least 2 areas; significant mood shifts within hours; significant anger; distrust in others; not having strong sense of identify; or chronic emptiness

Yes No

If yes to above question, please select those that apply below:

You deliberately hurt yourself physically (punch yourself, cut yourself, burn yourself)

You have experienced impulsivity in at least two areas - and which create problems for you (e.g., eating binges, pending sprees, drinking too much, verbal outbursts)

Your relationships are troubled by frequent arguments or repeated breakups

You would describe yourself as experiencing extreme moods (ups and downs) that shift even within a few minutes or hours

You often feel you have no idea who you are, or just generally like you do not have a clear sense of identity

You have made desperate efforts to avoid feeling abandoned or being abandoned (e.g., repeatedly asking for reassurance that someone cares, begging others not to leave you, or physically clinging to them not to leave

You often act in an angry or sarcastic manner

Additional Information

To ensure there is no conflict of interest, do you know anyone receiving services at OICBT (past or present), like family or friends?

Yes No

If yes, please include their full name:

Please note: Due to confidentiality we will be unable to confirm whether the person you named is receiving services or not at the OICBT. If they are, we will be sure to triage you to a therapist that was not involved in their care.

Do you have insurance coverage for mental health services?

Yes No

Do you have any coverage limitations we should be aware of? (e.g., Coverage by only certain types of health professionals)

Yes No

Please indicate which disciplines ARE covered by your insurance

Psychology

(Includes Psychologist, Psychologist under Supervised Practice, Psychology or Psychotherapy Resident or Practicum Student)

Registered Psychotherapist

Occupational Therapist

Social Worker

Who is your insurance coverage under/with? Please Note: We do not do direct billing. We only do direct billing for DND, CAF, RCMP.

DND/CAF VAC/PCVRS RCMP WSIB

Please Note: We do not do direct billing for WSIB.

HCAI

Please Note: We do not do direct billing for HCAI.

MVA

Please Note: We do not do direct billing for MVA.

Other Insurance

Please note that you will need a referral through your case manager at CAF/DND to have services covered by CAF/DND, unless you intend to pay out of pocket without reimbursement.

K-number:

R-number or member number:

Insurance Company:

Case Manager's Name and Contact Number (& Extension):

For RCMP, VAC/PCVRS, CAF/DND (BlueCross) Clients Only:

While there is direct billing between OICBT and Medavie Blue Cross, they may decline coverage under the following circumstances: a) client declines Assessment or Progress Report(s) to be sent to RCMP Health Services, or b) a client’s presenting issue is non-work related. In such cases, clients will be required to pay OICBT directly for any services delivered (Assessment, Therapy, Reports, etc.).

Clients may be able to bill Sunlife directly for reimbursement; however, clients are responsible to verify what services will or will not be covered by their insurance.

The OICBT does not assume responsibility for services or payments that are not covered by your insurance company.

Do you have any general questions about OICBT/services you would like answered?

Please note: We will inform your clinician of these questions when completing this referral. If you require a response prior sooner, please contact our administrative department.

Name of Parent/Guardian completing this form:

Relationship to youth:

Please specify:

Next Steps

Once you have clicked the "Submit" button below, your screener will be sent to our administrative team. If we have questions for you or need more information, we will contact you based on your preferred method above within one week. If we do not need additional information, we will determine the best clinician and/or service to meet your needs and will contact you with your referral options within one week. Please keep an eye out for an email from us (info@oicbt.ca and/or ottawainstituteofcognitivebehaviouraltherapy_org@caredove.com) or a phone call from us via a blocked number.

If you have questions in the meantime, please reach out to our administrate team at 613-820-9931; ext. 0, or email us at info@oicbt.ca.

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