Register for Counselling

– Step 1 of 6

Please provide your Social Worker's phone number *

Is this child connected to a Child and Family Services Agency? *

For whom is this application? *

This is for myself
This is for a child in my care

If you are registering a school age child, please specify what school division they are a student of.

Please provide the name of the Agency: *

Please provide your Social Worker's name: *

We are currently conducting sessions in person, however video or phone options are also available. (Choose all that apply.) *

Available in person
Available to have a video session (this may require prepayment by credit card or e-transfer)
Available to have a phone session (this may require prepayment by credit card or e-transfer)

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Contact Information

Client's Name *

First

Last

Client's Birthday *

Client's Gender

Client's Personal Pronouns

she/her/hers
he/him/his
they/them/their
no pronoun; please just use my name

Client's Primary Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

By entering information in the following section, your consent for Chatrath Counselling Centre to contact you is implied.

Client's Primary Phone Number *

Client's Personal Email Address *

Confirm Email

Emergency Contact Person *

Emergency Contact's Phone Number *

Emergency Contact's Relationship to you *

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Type of Therapy

What type of service are you requesting? *

Individual Child/Youth
Individual Adult
Parent/Child
Couples
Family

What type of therapy are you requesting? *

Play therapy
Verbal therapy

What time are you available for sessions?

Daytime
Evenings
Weekends
All

Do you have a preference for a counsellor?

Cheryl-Lynn Chatrath
Dana Naismith
Colleen Boomer
Megan Braun
Tess Boomer-Ens
Patricia Audette
Naomi Evans
Cherish Payjack
No preference

Have you accessed services at Chatrath Counselling Centre before?

How did you hear about Chatrath Counselling Centre? (Choose more than one if applicable)

Psychology Today
Website (online search)
Social media
Word of mouth (family, friend, colleague)
Employer
School
Family doctor
CFS or other social agency
Other
I am a returning client

Please provide the name of the family member, friend, or colleague:

Please provide the name of the agency:

Please provide the name of the family doctor:

Please provide the name of the school and school personnel:

Please provide the name of your employer:

Other:

Accessibility – Please indicate any accessibility needs you have that we should be aware of when accessing services at our centre

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Thank you for providing us with that information. The following questions are to help us understand your reasons for requesting therapy at this time and so that we can match you with the best fitting therapist for your needs.

Please describe your Challenges/Concerns

Please select the topic(s) below that are concerns for you at this time. *

2SLGBTQQIA concerns
Abuse (emotional, mental, physical, sexual, spiritual)
Addiction
Anger
Anxiety/Anxiety Disorders
Childhood Trauma
Chronic Pain
Defiant Behaviour (ODD, Aggression)
Depression/Depression Disorders
Developmental Difficulties
Emotional Regulation
Gender Identity
Grief, Bereavement & Loss
Intimate Partner Violence
Mood Disorders
Parenting Skills/Attachment Concerns
Personality Disorders
Relationship Challenges/Difficulties
Schizophrenic/Psychotic Distorders
Self-Esteem
Self-Injury
Separation/Divorce
Sexuality/Sexual Identity
Sexual Violence/Sexual Assault
Sleep Disturbances
Social Skills
Spectrum Disorders
Spirituality
Stage of Life Issues
Stress & Overwhelm
Suicidal Ideation
Trauma (PSTD, C-PSTD)

Are you currently having suicidal thoughts/thoughts of harming yourself? *

Please call 911 or one of these agencies for help: Manitoba Suicide Prevention & Support Line (24/7) – 1-877-435-7170 Crisis Line (24/7) – (204) 786-8686, 1-888-322-3019 MB Farm, Rural & Northern – Support Services – 1-866-367-3276 Sexual Assault Crisis Line (24/7) – (204) 786-8631 – 1-888-292-7565 Human Trafficking Hotline (24/7) – 1-844-333-2211

Have you had suicidal thoughts/thoughts of harming yourself in the past? *

Are you currently having thoughts of harming others? *

Please note that someone from our team will be following up to check in on you. If you are struggling with thoughts of harming yourself or others, please call the Steinbach Crisis Stabilization Unit at 855-320-1096.

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Please list up to three (3) of your greatest concerns that you would like to address in counselling at this time.

Concern #1 *

Concern #2

Concern #3

What do you hope will change as a result of coming for counselling?

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Financial Information

Thank you for your application! The next step if for us to determine your rate for services and method of payment.

Do you have insurance coverage for counselling services? *

If you answered yes to the above question, what are you covered for? (click all that apply) *

Registered Psychologist
Social Worker
Counsellor
Psychotherapist

If you know what your insurance coverage allows for in terms of the yearly maximum, please enter the number of sessions covered below.

If you know, please enter the date of when your insurance resets during the calendar year.

Presently, Chatrath Counselling Centre does not offer direct-billing to insurance providers. You will be responsible to submit your receipt to your insurance company. You are also responsible for keeping track of your coverage amount. Please let us know when your coverage has been exhausted.

Are you covered with alternative benefits such as: (click all that apply) *

FNIHB
Workers Compensation (active file open)
Victim Services
Employee Assistance Program (EAP)
Other
None

Other:

FNIHB = please enter your Status Number *

WCB Case Worker's Name *

WCB File Number *

WCB Case Worker's Phone Number *

Victim Services Case Worker's Name *

Victim Services File Number *

Victim Services Case Worker's Phone Number *

EAP generally selects their clinicians randomly. Do you specifically wish to see someone at Chatrath Counselling Centre? *

Yes
Not necessarily

Direct billing is offered when clients are approved for services and counselling supports by the benefit agencies.

Please call EAP at 204-786-8880 to learn about what programs may be available to you.

If you are not using insurance, or will be using our sliding scale fees to cover the cost of sessions, your fees for service will be assessed based upon your household income and the number of dependents living with you. Sliding scale rates apply to sessions booked with Clinic Practicum Student for individuals with limited or no insurance for counselling.

Acknowledgement *

I have read and understand these terms.

Will you be using insurance? *

If you are not using insurance, or will be using our sliding scale fees to cover the cost of sessions, your fees for service will be assessed based on your household income and the number of dependents living with you.

Please select your annual household income. *

$9,999 and under
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 to $89,999
$90,000 to $99,999
$100,000 and over

Please select the number of people living in the home. *

I am alone.
One dependent and myself
Two dependents and myself
Three dependents and myself
There are 5 or more of us.

Thank you for providing us with this information. In order to determine your session rate, we will need a copy of some documentation which verifies your income. This may include a notice of assessment or letter from EIA. Please submit your income verification document to us at intake@chatrathcounsellingcentre.com. Please ensure you have put your name and contact information in the body of the email.

PLEASE NOTE: Just as our clients reserve the right to terminate services, the Chatrath Counselling Centre (CCC) also reserves the right to terminate or deny services. There may be reasons why CCC determines that we will need to deny or terminate services. In general, CCC strives to ensure that all of our services are professional and an appropriate fit for the needs of our clients. In situations where our ethics may be compromised──or where clients’ needs extend beyond the services we are equipped to offer──we will refer to other agencies who are better equipped to support your needs

Terms of Engagement between Chatrath Counselling Centre and the Client *

I acknowledge that I have read and agree to the Terms of Engagement

NOTE: The Terms of Engagement is to be read and acknowledged by all custodial parents and legal guardians of children whose parents are separated or divorced and whereby the child is receiving services.

Terms of Engagement:

Chatrath Counselling Centre is committed to working in the best interest of the client. When the client is a child whose parents have separated or divorced, the focus will always be directed towards the needs of the child.

Given the potential emotional/stressful nature of the separation/divorce process, one or both parents may feel the need to process their own issues or concerns about the other parent. However, to avoid drawing the focus from the child’s need, no time will be spent addressing the parents’ issues/concerns. The counsellor assigned to the child, may encourage parent(s) to seek out their own individual counselling support separate from that of their child’s sessions and counselling process.

It is important to note that the Chatrath Counselling Centre reserves the right to immediately cease services upon the determination that any client – active or referred – is or has become actively involved in custody proceedings.

The Chatrath Counselling Centre also reserves the right to refuse or terminate services that involve legal proceedings.

Furthermore, this document confirms the following:

That you have requested/consented to counselling and therapeutic services.

That you are prepared and committed to allow Chatrath Counselling Centre to work alongside your child(ren) through any personal struggles and challenges you/they may face.

That you have advised us that you have completed court proceedings regarding separation/divorce and that no time will be spent discussing issues related to the past court proceedings as a part of your child(ren)’s counselling process and sessions.

That you have been advised that we are prepared to provide the counselling and therapeutic services within the scope of our ethical and professional practice.

That you are prepared to take responsibility for bringing your child(ren) to their scheduled counselling sessions (during periods of your care and control)

That you have been advised and that you have agreed to fund the services as discussed with your counsellor.

That neither party shall make derogatory comments about the other while the child(ren) is/are present; and

That you have agreed that these services are provided on the condition that:

The counselling and therapeutic services are offered in confidence, in accordance with normally accepted legal standards

The therapist or counsellor providing the service will not be called by either party to testify in any Court Proceedings against the other;

The therapists and counsellors providing the service will not provide reports for any court purpose or to any third party outside of the scope of a CFS contracted service to which the reports are provided to the CFS agency with whom the contract is signed.

Click to print and complete the Terms of Engagement Form

Client Informed Consent *

I acknowledge that I have read and agree to the Client Informed Consent

INFORMED CONSENT FOR MENTAL HEALTH SERVICES/SUPPORTS

Consent to Participate

Counselling at Chatrath Counselling Centre involves taking part in a process of addressing personal challenges with a professionally trained counsellor, to achieve more fulfilling individual lives or couple/family relationships. This process of change will be unique to your situation. It will consist of:

Clearly defining problem areas

Establishing therapeutic goals

Determining an intervention plan

Participating in an evaluation

Successful counselling and problem resolution require your active participation, as well as a serious commitment; therefore, it should not be entered into lightly. Prior to agreeing to this process, individuals have a right to ask the counsellor about their qualifications, background, and therapeutic orientation. In addition to a qualified counsellor, the match between client and counsellor will influence counselling outcomes. Clients are encouraged to voice any concerns to ensure services are best suited to their, needs. To best deliver therapeutic assistance to children, individuals, couples, and families, we have developed certain policies and procedures.

They are as follows:

APPOINTMENT SCHEDULING: Clients are asked to attend each session as scheduled. The sessions are 50 minutes in length. Should it become necessary to cancel an appointment, we require a minimum of 24 hours’ notice. Failure to provide 24 hours’ notice for cancellation or re-schedule may result in a full session fee charged.

INSURANCE: It is the client’s responsibility to enquire with their insurance providers to determine if services will be covered. By initialling, the client acknowledges they have been advised and encouraged to enquire with the insurance provider prior to beginning services to ensure coverage. Contract counsellors with Chatrath Counselling Centre will have varying credentials in the mental health profession. It is the client’s responsibility to enquire with their individual insurance companies to determine if their session with any counsellors associated with Chatrath Counselling Centre.

CONFIDENTIALITY: According to professional ethics and federal and provincial laws, all counselling sessions are strictly confidential between client and counsellor/therapist. However, there are certain limitations to confidentiality as outlined in this information package which has been read and understood.

SUPERVISION OF UNATTENDED CHILDREN: Chatrath Counselling Centre requires children under the age of 12 to be supervised by an adult. Please note that children must always be supervised while in the waiting area. We are not able to provide childcare and supervision while you are in session.

FEES: Session fees are: $115.00 per 50-minute session (if client pays), $125.00 per 50-minute session (if direct billed to a 3rd party), or $150.00 per 50 minute session (if direct bill to a 3rd party with no ability to enforce late cancel/no show policy) and are to be paid upon completion of each session. We accept cash, cheque, Visa, MasterCard, and e-transfer as forms of payment. An administration fee of $25.00 will be added to any NSF (non-sufficient funds) cheques. Subsequent sessions cannot be scheduled without payment receipt of previous appointments. Masters Candidate Practicum Student(s) full session fees are charged until eligible insurance maximums are reached; sessions thereafter will be billed at a rate of $50 ($47.50 + GST).

TERMINATIONS: Clients have the right to terminate counselling at any time. However, we encourage discussion with the therapist so that sufficient closure can take place. Please note that, due to Chatrath Counselling Centre policy and practice limiting involvement with legal involvement specific to child custody disputes, we cannot provide service involving minor children actively involved in legal proceedings. In the event that a client is found to be involved in such circumstances, services will be terminated. Once legal proceedings are completed, service can be resumed.

CRISIS SERVICES: Emergency services are not provided by Chatrath Counselling Centre. If you need immediate assistance, the following are some resources available:

KLINIC Crisis Line at 204-786-8686 • Crisis Stabilization Centre at 204-940-1781 • Youth Crisis Stabilization System at 204-949-4777 • Manitoba Suicide Line at 1-877-435-7170

RESPECTFUL WORKPLACE: Please note that Chatrath Counselling Centre is committed to a positive environment in which all individuals (staff and clients) are treated with compassion, respect, and dignity. Abuse and harassment in any form (verbal, emotional, physical, sexual) will not be tolerated and may result in termination of services. We reserve the right to refuse services.

Click to download, print, and complete the Informed Consent Form

Parental Informed Consent for Youth *

I acknowledge that I have read and agree to the Parental Informed Consent for Youth

PARENTAL INFORMED CONSENT FOR YOUTH UNDER 16 YEARS

Parental Consent for Counselling/Therapy Participation

Counselling at Chatrath Counselling Centre involves taking part in a process of addressing personal challenges with a professionally trained counsellor, to achieve more fulfilling individual lives, or couple/family relationships. This process of change will be unique to your child’s situation. It will consist of:

Clearly defining problem areas

Establishing therapeutic goals

Determining an intervention plan

Participating in an evaluation

Prior to agreeing to this process, it is important to understand that the person for whom the sessions are scheduled is defined to be “the client”. In this context, your child for whom you are consenting is considered “the client”.

Individuals (client and parents) have a right to ask the counsellor about their qualifications, background, and therapeutic orientation. In addition to a qualified counsellor, the match between the client and counsellor will influence the outcomes of counselling. Individuals (client and parents) are encouraged to voice any concerns to ensure services are best suited to the client’s needs. To best deliver therapeutic assistance to children, individuals, couples, and families, we have developed certain policies and procedures. They are as follows:

APPOINTMENT SCHEDULING: Clients are asked to attend each session as scheduled. A parent will be provided with an email reminder of upcoming appointments. The sessions are 50 minutes in length. Should it become necessary to cancel an appointment, we require a minimum of 24 hours’ notice. Failure to provide 24 hours’ notice for cancellation or re-schedule may result in a full session fee charged.

INSURANCE: It is the parental responsibility to enquire with their insurance provider(s) to determine if services will be covered. By checking the box/initialling, the parent acknowledges they have been advised and encouraged to enquire with their insurance provider(s) prior to beginning services to ensure coverage. Contract counsellors with Chatrath Counselling Centre will have varying credentials under the mental health profession. It is the client’s responsibility to enquire with their individual insurance companies to determine if their session with any counsellors associated with Chatrath Counselling Centre.

CONFIDENTIALITY: According to professional ethics and federal and provincial laws, all counselling sessions are strictly confidential. However, there are certain limitations to confidentiality as outlined in this information package which has been read and understood. I understand that these confidentiality rights apply to the child for whom I am consenting as they are the client. As a parent, I understand that I am not going to be privy to the content/discussion of the counselling sessions as protected by the parameters of confidentiality. I have read the confidentiality information sheet (attached) and the above statement and agree to the above terms

SUPERVISION OF UNATTENDED CHILDREN: Chatrath Counselling Centre requires children under the age of 12 to be supervised by an adult. Please note that children must always be supervised while in the waiting area. We are not able to provide childcare and supervision while you are in session. Should you be accompanying one child to participate in one of their therapy sessions, we ask that other children are not attending the Centre with you if they require your supervision. We are not able to accommodate waiting room space for accompanying individuals (adults or children) who are not directly engaging in sessions.

FEES: Sessions are: $115.00 per 50-minute session (if client pays), $125.00 per 50-minute session (if direct billed to a 3rd party), or $150.00 per 50 minute session (if direct bill to a 3rd party with no ability to enforce late cancel/no show policy) and fees are to be paid upon completion of each session. We accept cash, cheque, Visa, MasterCard, and e-transfer as forms of payment. An administration fee of $25.00 will be added to any NSF (non-sufficient funds) cheques. Subsequent sessions cannot be scheduled without receipt of payment of previous appointment(s). Masters Candidate Practicum Student(s) full session fees are charged until eligible insurance maximums are reached, sessions thereafter will be billed at a rate of $50 ($47.50 + GST).

TERMINATIONS: Clients and parents of children/youth deemed not of maturity to consent, have the right to terminate counselling at any time. However, we encourage discussion with the therapist so that sufficient closure can take place. Please note that, due to Chatrath Counselling Centre policy and practice limiting involvement with legal involvement specific to child custody disputes, we cannot provide service involving minor children actively involved in legal proceedings where custody is in dispute and joint consent is not provided. If a client is found to be involved in such circumstances, services will be terminated. Once legal proceedings are completed, service can be resumed. I am aware of the policy in working with children/youth who become involved in child custody disputes and agree to notify my child/youths counsellor should any proceedings of this nature evolve after the initial starting point of counselling services.

CRISIS SERVICES: Emergency services are not provided by Chatrath Counselling Centre. If you need immediate assistance, the following are some resources available:

KLINIC Crisis Line at 204-786-8686

Crisis Stabilization Centre at 204-940-1781

Youth Crisis Stabilization System at 204-949-4777

Manitoba Suicide Line at 1-877-435-7170

RESPECTFUL WORKPLACE: Please note that Chatrath Counselling Centre is committed to a positive environment in which all individuals (staff, clients, and client families) are treated with compassion, respect, and dignity. Abuse and harassment in any form (verbal, emotional, physical, sexual) will not be tolerated and may result in termination of services. We reserve the right to refuse and terminate services for reasons in breach of this policy.

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CHATRATH COUNSELLING CENTRE

90 Brandt St. Suite #2, Steinbach, MB R5G 2K2

431-205-3404

intake@chatrathcounsellingcentre.com

We accept payment by: E-TRANSFER • CREDIT CARD • CHEQUE

If this is an emergency, please call 911. KLINIC Crisis line: 204-786-8686; Crisis Stabilization Centre: 204-940-1781; Youth Crisis Stabilization System: 204-949-4777; Manitoba Suicide Line: 877-435-7170.

Chatrath Counselling Centre acknowledges its location on Treaty 1 land, the original territory of the Anishinabe, Cree, Oji-Cree, Dakota, and Dene peoples, and the homeland of the Metis Nation.