Client Information and Agreement
CECILIA DING               SELF-GROWTH COACH  and COUNSELOR                WWW.CECILIADING.COM

Please answer as completely as you can to help me prepare for our session; however, only questions with * are required before submission. If you are a couple, please fill one out for each.  Thank you.

*After you have finished the form, please use think link to schedule an appointment
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Basic Information
First and Last Name *
Date of Birth *
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DD
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Phone Number *
Current Address *
Emergency Contact: Name and Phone Number *
Country of Birth
Education and Employment
Highest degree completed in school
Clear selection
Education and Employment
Current employment status
Clear selection

Family Background
Please give information, as applicable, about the quality of your relationship to people close to you. Use as much space as you need.

1. Spouse/Partner 

2. Children/Dependents

3. Mom

4. Dad

5. Others(Please Specify)

Check all the statement(s) below that apply to the type of family you grew up in: 

Overall Health History

Please list significant medical problems/conditions, and indicate if you are receiving treatment for them; if none, write "na": 

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Do any of these problems affect your everyday life?  If yes, how is it affecting you? 

Briefly describe any surgeries or hospitalizations for serious illness or injuries (What, where, when, etc.), if none, please write "na".

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Have you ever blacked out / lost consciousness and/or experienced any type of serious head injury or trauma? If so, please indicate when and what happened. If none, please write "na".

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Are you on prescribed medication? If so, please give details of the medication: 1.who is prescribing it, 2. for what condition,  and 3. for how long you’ve been taking it. If none, please write "na"

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Do you currently have thoughts of harming yourself? If yes, please describe briefly. If none, please write "na". 


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Have you had thoughts of harming yourself in the past? If Yes, please describe:

Have you ever experienced a problem with alcohol, drugs, or prescription medications? If yes, please describe.  

Have you had counseling or coaching before or currently seeing someone? If yes, please describe briefly what helped and what did not help.

Please describe in detail the motivations that led you to seek my support. Please use as much space as you would need. How long have you felt this way? What made you decide to reach out now? 

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If there is anything else you would like to share, please fill in below. 

Thank you for your time filling out the form,  please read the information on fee, confidentiality and agreements below, sign your name and submit. I look forward to meeting you. 

Fees

Regular session fee is on a sliding scale of USD 150 to USD 215 per 50 minute session. You can choose what you pay each time and there is no questions asked and you do not need to inform me ahead of time. 

Appointment Cancellation Policy: In the event that you must cancel or reschedule a session, please inform Cecilia as soon as possible through email. You are asked to pay the full fee for each missed session without twenty-four hour notice provided.

Payment: You will be charged through the payment information entered in the Theranest intake form. 

Professional Ethics: I, Cecilia Ding, subscribe to the Code of Ethics and Standards of Practice of the American Counseling Association (http://aca.convio.net)，ICF Code of Ethics, Canadian Counselling and Psychotherapy Association. 


Confidentiality and Release of Information: In recognition that confidentiality is an integral part of successful relationship, I maintain confidentiality with respect to every aspect of the treatment process, including a client’s name. In no situation, except as is necessary for case consultation with another professional or as required by law, will I reveal any aspect of your personal information. In all other circumstances, release of information requires your express written consent.  

Waiver of Liability. From time to time, I attend provide peer guidance and case consultation with my peer group, and general details of cases are shared in this confidential supervision process. 


By signing this waiver of responsibility, you release Cecilia Ding from any real or perceived liability arising out of the services provided. 

By signing my name and the date below, I agree that I have read the information above and agree to abide by these policies. In the case of any disagreement, conflict or misunderstanding, I agree to work within a mutually agreed mediation process. I will not under any circumstances pursue litigation against Cecilia Ding.

 

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After you have completed, please schedule an session here: Appointment Calendar
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