Welcome to Catholic Family Services of Durham Walk-In Counselling Clinic

Please read the following service features and direct any questions to reception.

o We provide Single Session counselling and operate on a first come first served basis

o At a Walk-In Single Session, a clinician will work with you to create a plan and identify possiblenext steps to begin desired change.

o A Single Session is about 1 hour long and clients are generally seen in order of arrival, althoughsome may be seen on a priority basis depending on their presenting issue. If a large influx ofindividuals comes in we may have to ask you to return to the next clinic.

o We ask that you complete the Walk-In Package to the best of your ability. If you require anyhelp, please ask.

o Once completed, please give the package to reception and then the Intake Screener will meetwith you to discuss what you are seeking help with today, set up your appointment, andnegotiate the fee for your session. Our fee schedule, ranging from $5.00 to $65.00 is based ontwo factors: family income and number of dependents. We will adjust your fees to fit yourcircumstances.

o It is an agency expectation that parents or legal guardians remain on agency premises whileminors (under 12) are at the agency for counselling. Therapists may require parental input orsupport at any time during the session and parents are to be available to children as needed. Inexceptional circumstances where this may not be possible, any parent or legal guardian whochooses to leave a child on site without a guardian present is required to sign a waiver releasingCatholic Family Services of any liability while their child is on the premises.

o At the end, we ask that you take the time to complete a survey to let us know how you felt aboutthe Single Session you attended. This anonymous information is used to report to our funderson how helpful the program has been to participants.

o If it is deemed to be appropriate by the counsellor, your name may be placed on the waiting listfor individual, couple or family counselling until space becomes available.

o You may return to the walk in up to once in a four week period to receive another session. Please note that you may not seem the same clinician in subsequent visits

o We are a teaching agency, therefore, the clinician who meets with you may be working towardsa Master’s degree and is being supervised by a Master’s level staff person. Additionally, thismay mean that more than one clinician could be present for your session, for learning purposes.

o Please note, we are a scent-free office.

Please note: We do not provide letters or reports for clients of the Walk-In Clinic.

Please read and complete the attached package

CONFIDENTIAL FAMILY INFORMATION (Please Print)

Person 1 Person 2 Last Name _______________________________ _______________________________ First Name _______________________________ _______________________________ Date of Birth (m/d/y)_____________________________ _______________________________ Address _______________________________ _______________________________ City _______________________________ _______________________________ Postal Code _______________________________ _______________________________ Home Phone # _______________________________ _______________________________ Cell/Business # _______________________________ _______________________________ Occupation _______________________________ _______________________________ Email address _______________________________ _______________________________ Education _______________________________ _______________________________

Partner information:

Child Name(s) School Relationship Birth Date (m/d/y) Gender __________________ _________________________ _________ __________________ _____ __________________ _________________________ _________ __________________ _____ __________________ _________________________ _________ __________________ _____ __________________ _________________________ _________ __________________ _____ __________________ _________________________ _________ __________________ _____

Ethnicity refers to roots or ancestral origin, not citizenship or nationality:

□ African □ Chinese □ Guyanese □ Pakistani

□ American □ Dutch □ Hungarian □ Polish

□ Arabic □ Filipino □ Indian □ Portuguese

□ Asian □ French □ Irish □ Scottish

□ British □ French Canadian □ Italian □ Ukrainian

□ Canadian □ German □ Latin American □ Other (specify)

□ Caribbean □ Greek □ Native Canadian ________________

Do you have any French heritage? □ Yes □ No

Would like services in French? □ Yes □ No

Voulez- vous les services en français? □ Oui □ Non

Do you have any Aboriginal heritage? □ Yes □ No

Relationship Status:

□ Common Law □ Divorced □ Married

□ Single □ Separated □ Widowed

Walk‐in Screening Form 

How did you find out about CFSD? Who referred you? 

            Doctor/Hospital    Community Program          Mental Health Service (e.g. CMHA, Family Health Team, Wendat)  

           Probation/Police    Children’s Aid Society        School/Adult Learning Program         Family/Friend        Lawyer         

         Other Professional     Self (includes phone book or internet)     Faith community (priest/minister) Other:   

 

      1. Have you been to our Walk‐In Counselling Clinic before?  □ Yes □No  

      2. Do you have an ongoing worker with CFSD?      □ Yes □No   If yes, name of worker:  ________________________ 

         3.  What do you want to talk a counsellor about today?  (Please be as specific as possible)     4.  If 1 is the best and 10 is the worst, how are things in your life today?                                 

Best      1       2       3      4      5      6      7      8      9      10     Worst 

5.  a) Are you currently at any risk of committing suicide?    □Yes □No 

      b) Are you currently at risk of harming yourself?  □Yes □No 

6.   Are you currently at risk of harming others?   □Yes □No  

7.  Are you currently involved in any court or legal processes that is affecting why you are here today? □Yes □No    

      If yes, please specify the type of legal involvement:_________________________________________________ 

8.  Are you currently involved in any addictive behaviours (i.e. drugs, alcohol, gambling)? □Yes □No 

     ________________________________________________________________________________________ 

9. Do you have a Family Doctor?       □Yes □No 

If yes, name of doctor: _________________________________________ 

10.  Is your family currently involved with the Children’s Aid Society?    □Yes □No  

      If yes, name of worker: __________________________________________    

     11.  Have you recently been in contact with bed bugs?    □Yes □ No         12. Is there anything else that you would want the counsellor to know before your appointment? 

        

          Counselling Request      What type of counselling are you requesting today?      Individual  Couple    Family     Group 

     Do you or your partner have insurance or an EAP program that covers counselling?     □ ME     □ MY PARTNER 

Walk‐in Screening Form

Income Information and Fee Calculation  

Please provide the following income information to assist us in setting an affordable service fee. 

Income Source (per annum) Client Spouse/Partner 

Employment Income 

(net)/WSIB 

 

Ontario Works/ODSP   

Employment Insurance   

GST   

CPP   

Child Tax Benefit   

Other Government 

Income/Support 

 

Alimony/Child Support   

Other Source: (i.e. 

investment, rental income) 

 

Sub‐total:   

Total household income: 

# of dependant family 

members: 

 

 

 

 

Office Use Only 

Cost of session:       $65.00   Fee based on scale:_______ 

Fee to be paid by client:   ______  

Amount to be subsidized by CFSD:  ______ 

Reason(s) to adjust fee: 

_______________________________________________________________________________

_______________________________________________________________________________

This section to be filled out by staff:

Code #: Date Office Location: Program

Before Walk-In Survey This survey will help us understand the impacts of our walk-in program. We will ask you

the same questions again after service, along with some questions about your experience. This is an anonymous survey, so please do not put your name on the form.

Part 1. Please read each item carefully and select the response that best describes how you think about yourself right now. Before you start, take a few moments to focus on yourself and what is going on in your life.

Please tell us how much you agree with the statements below.

strongly disagree disagree neutral agree

strongly agree

If I should find myself in a problem, I could think of many ways to get out of it.

1 2 3 4 5 n/a

At the present time, I am energetically pursuing my goals. 1 2 3 4 5 n/a

There are lots of ways around any problem that I am facing now.

1 2 3 4 5 n/a

Right now, I see myself as being pretty successful.

1 2 3 4 5 n/a

I can think of many ways to reach my current goals. 1 2 3 4 5 n/a

At this time, I am meeting the goals that I have set for myself.

1 2 3 4 5 n/a

Part 2. Where would you have gone for help if you had not come to the walk in clinic today?

o Emergency Department o Spiritual Leader o Other

o Family Doctor o Other Agency o Prefer not to answer

o Walk-in Medical Clinic o Family & Friends o Nowhere