Registration RM_StatsPage 1Username *Password *Password must be at least 7 characters long.Enter password again *Password must be at least 7 characters long.Email *First Name *Last Name *Birth Date *Home or Residential Address Address Line 1 Address Line 2 City State or Region State or Region United States Canada Zip Primary Phone * Home Work Mobile OtherPrimary Phone Number *Can we leave a message at the primary phone number * Yes No Secondary Phone Home Work Mobile OtherSecondary Phone NumberCan we leave a message at the second phone number? Yes No Should we add a contact person to your file? If yes, please provide their information.(Full name and phone number)Preferred Language * English French OtherEmployment SituationPlease Describe BrieflyHave you attended counselling previously * Yes No If "Yes", please specify what type of counselling Group session Individual session Family session Telephone session Online session OtherAny comments on previous counselling?Your AnswerReasons for this request of services *Your AnswerDo you currently take any medication? * Yes No If "Yes", please provide more informationPlease indicate type & quantity of medicationIf "Yes", do you take in accordance with the applicable directions and/or as prescribed? Yes No Any comments on medication intake?Your AnswerDo you have any issues with the following (past or present)? Issues are separated into categories (personal, family/relationship, trauma, addiction and work). Personal ADD/ADHD diagnosticsSelect an optionPastPresentN/AAnger managementSelect an optionPastPresentN/AAnxiety managementSelect an optionPastPresentN/ABereavement/griefSelect an optionPastPresentN/ADepressionSelect an optionPastPresentN/ABurnoutSelect an optionPastPresentN/AChronic illnessSelect an optionPastPresentN/AEating disorderSelect an optionPastPresentN/AEnd of life supportSelect an optionPastPresentN/AFinancial difficultiesSelect an optionPastPresentN/AGuidance counselingSelect an optionPastPresentN/AHarassment concernsSelect an optionPastPresentN/AInsomniaSelect an optionPastPresentN/ALearning difficultiesSelect an optionPastPresentN/ALGBTQ+ issuesSelect an optionPastPresentN/ALife transitionSelect an optionPastPresentN/AMental health issuesSelect an optionPastPresentN/AMulticultural realitiesSelect an optionPastPresentN/ANutritionSelect an optionPastPresentN/APain managementSelect an optionPastPresentN/APersonality disorderSelect an optionPastPresentN/APhobiasSelect an optionPastPresentN/APost-partum depressionSelect an optionPastPresentN/APsychological diagnosisSelect an optionPastPresentN/APTSDSelect an optionPastPresentN/ASelf-esteemSelect an optionPastPresentN/ASelf-harmSelect an optionPastPresentN/ASexual health issuesSelect an optionPastPresentN/AStress managementSelect an optionPastPresentN/ASchool related issuesSelect an optionPastPresentN/ASuicidal ideationsSelect an optionPastPresentN/AIf your past and/or present personal issue is not listed above, please enter it belowFamily/relationship Blended familySelect an optionPastPresentN/ACareer counsellingSelect an optionPastPresentN/ACouple therapySelect an optionPastPresentN/ADrug dependenceSelect an optionPastPresentN/AEldercareSelect an optionPastPresentN/AExtended familySelect an optionPastPresentN/AFamilial therapySelect an optionPastPresentN/AFamily dynamicsSelect an optionPastPresentN/AFamily substance abuseSelect an optionPastPresentN/AMediationSelect an optionPastPresentN/AParent-child relationshipsSelect an optionPastPresentN/AParenting strategiesSelect an optionPastPresentN/ARelationship issuesSelect an optionPastPresentN/ASeparation/divorceSelect an optionPastPresentN/AIf your past and/or present family/relationship issue is not listed above, please enter it belowTrauma Assault/robberySelect an optionPastPresentN/AChildhood abuseSelect an optionPastPresentN/ADomestic violenceSelect an optionPastPresentN/ASexual violenceSelect an optionPastPresentN/ASubstance abuse issuesSelect an optionPastPresentN/ATraumatic eventSelect an optionPastPresentN/AVictimizationSelect an optionPastPresentN/AViolenceSelect an optionPastPresentN/AViolent behaviorSelect an optionPastPresentN/AWork related issuesSelect an optionPastPresentN/AAddiction AlcoholSelect an optionPastPresentN/ADrugsSelect an optionPastPresentN/AGamblingSelect an optionPastPresentN/AIllicit substanceSelect an optionPastPresentN/AInternetSelect an optionPastPresentN/APrescribed medicationSelect an optionPastPresentN/ASexualSelect an optionPastPresentN/AIf your past and/or present addiction issue is not listed above, please enter it belowWork CareerSelect an optionPastPresentN/AConflictSelect an optionPastPresentN/AStressSelect an optionPastPresentN/AUnemploymentSelect an optionPastPresentN/ADisability/return to workSelect an optionPastPresentN/AOrganizational changeSelect an optionPastPresentN/APerformance issuesSelect an optionPastPresentN/AWork life balanceSelect an optionPastPresentN/AIf your past and/or present work issue is not listed above, please enter it belowComments regarding any issue stated in the above sectionExpectations from services * *Page 2Consent to Treatment FormThis form is to be read and signed by the client. It is valid for a period of one from the date of signature. Services *I AgreeYour assigned clinical therapist, counselor or facilitator is a member of an association, college or professional organization. Your assigned professional’s treatment plan consists of working towards the reason for the request of services, following the objectives you establish together during the first session. If after discussion, another resource is recommended to better suit your needs, your clinical therapist, counselor of facilitator will provide you with guidance during this process. Sessions will be offered only online through the website www.eros-inc.caConfidentiality *I AgreeConfidentiality is an essential part of any clinical relationship. All aspects of your participation in clinical services at EROS-Emotions Reactions Options Solutions Inc. (“EROS”), including scheduling of appointments, content of counselling sessions, and any records that we keep, are confidential (the “Confidential Information). Your Confidential Information may only be disclosed under the following circumstances: - in order to respond to the suspicion of child abuse; - in an attempt to address the risk of harm by the client to herself/himself or others; - if the client has given his or her consent and signed a specific authorization for the release of Confidential Information; - or if EROS or the assigned clinical therapist, counselor or facilitator is required by law to release your Confidential Information. The law requires to report any current or suspected child abuse situation and, as part of professional ethics, to do all that is necessary to protect life when there is a clear and imminent risk of harm to the child, self or others. It is to be noted that information may be shared with EROS’ management team for file management, or for insurance and quality assurance purposes. You may access your own clinical record within 48 hours (working days) by sending your written request by email to eros@eros-inc.ca.Scheduling AppointmentsI AgreeThe client is entirely responsible for the scheduling of appointments. When scheduling an appointment, the client is asked to choose a treating professional based on his or her field of expertise according to the reason for the request of services. Each professional’s description can be found on the professional’s profile on the EROS website. You will then receive an appointment confirmation via email. When cancelling a session with less than 24 hours notice, the client is entitled to a 50% refund. When cancelling a session with more than 24 hours notice, the client is entitled to a refund of the full amount. Please be advised that the client’s request for refund must be sent to eros@eros-inc.ca within three months of the date of the appointment in order to obtain a refund. The client is responsible to complete this form as well as a Client Information Form before the client’s first scheduled appointment through EROS.Values and beliefs : EROS’ Code of Conducts is based on the values of impartiality, honesty and respect in regards to its clients. EROS is committed to respecting its clients in all areas and committed to providing quality services to its clients at all times. Please Enter Today's Date *Acknowledgment *I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.Under the Electronic Transactions Act, RSNB 2011, c145 : - A legal requirement that information be in writing is satisfied by electronic information that is accessible so as to be usable for subsequent reference. 2001, c.E-5.5, s.7- A legal requirement for the signature of a person is satisfied by an electronic signature. 11(2)Without limiting the definition “electronic signature” in section 1, an electronic signature may be (a) an electronic representation of the manual signature of the person signing the document, or (b) electronic information by which the person signing the document (i) provides his or her name, and (ii) indicates clearly that the name is being provided as his or her signature to the document. 2001, c.E-5.5, s.10Signature Note: It looks like JavaScript is disabled in your browser. 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