| REGISTRATION FOR COUNSELLING | |
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| Please fill out the form below to register online for counselling services and self help courses. | |
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| *Name: | | |
| *Email: | | |
| *Address: | | |
| Telephone: | | |
| *Birthdate | | |
| Occupation | | |
| *Reason for Counselling: | | |
| Spiritual Background | | |
| Social Supports | | |
| Previous Counselling |
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| Details of Counselling | | |
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| RISK ASSESSMENT | |
| *Do you ever take action to harm yourself in any way? |
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| If yes, please state what you do. | | |
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| **PLEASE NOTE** | |
| IF YOU ARE SUICIDAL, YOU NEED TO ACCESS EMERGENCY SUPPORT IN YOUR OWN AREA. | |
| DO NOT WAIT FOR ONLINE COUNSELLING SUPPORT. DIAL YOUR EMERGENCY NUMBER IMMEDIATELY!!! | |
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| *Are you considering attempting suicide? |
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| IF YES, CONTACT EMERGENCY SERVICES NOW! (Dial 911 in North America.) | |
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| *Suicide Risk (Check all that apply) |
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| *I agree to contact emergency services immediately should I ever become suicidal. |
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| Do you smoke, drink alcohol, or use drugs? |
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| If yes, please state what substance you use, how much, and how often. | | |
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| Do you have any current medical conditions or illnesses? |
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| If yes, please specify. | | |
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| *CONFIDENTIALITY AGREEMENT | |
| I am aware that Carolyn Waddell is a counsellor, and that all counselling is confidential. I am aware that this confidentiality extends to all issues except those which Carolyn Waddell is required by law to report. | |
| I am aware that Carolyn Waddell works with a team, for my benefit and her own support and accountability. I am also aware that the limited information shared with team members is completely confidential between the people involved. | |
| I am also aware that all matters of confidentiality and professional ethics will be respected in these consultations and supervisory process. | |
| Therefore, I give my permission to Carolyn Waddell to discuss information from my counselling with her supervisor and the professional team. | |
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| Please choose a user name and password to use for accessing the "Members" section on the website. If you do not choose a password, one will be created for you. | |
| *User Name | | |
| Choose Password | | |
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| Please check the types of counselling you are interested in. |
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| Please check the modes of counselling service delivery you are interested in. |
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| *required field | |
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| Please click submit and return this form to me. I will reply to you shortly. Thank you. | |
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