Picasso’s Garage Art Therapy Studio: in-take form

This form is designed to ensure, as a parent, you have received the information necessary to place your child or adolescent into Art Therapy counselling with me. Please read carefully and feel free to ask me any questions if you require further clarification.

Qualifications: I have an Honors B.D. in Graphic Design from OCADu, a Graduate Degree in Art Therapy from the Toronto Art Therapy Institute (DTATI), I am a Canadian Art Therapy Association (CATA) Member #34824648 and a member of the College of Registered Psychotherapists of Ontario (CRPO) R.P. #008119
WHAT IS ART THERAPY?
Art therapy combines the creative process and psychotherapy, facilitating self-exploration and understanding. Using imagery, colour and shape as part of this creative therapeutic process, thoughts and feelings can be expressed that would otherwise be difficult to articulate." (CATA)
An Example of What Can Occur in a Typical Session:
- The participant discusses recent events (similar to talk-based therapy)
- Art directives designed to assist children will be presented
- Themes arising can become starting points for art making
- The client is supported in leading themselves in their own process
- The art-making process can illuminate aspects of the one's life and emotional world
RISKS ASSOCIATED WITH ART THERAPY:
As with any psychotherapeutic process, long buried feelings may emerge. Your child may experience uncomfortable feelings like anger, guilt, frustration, sadness or helplessness before they feel better. Art Therapy is a personal journey and there are no guarantees of what will be experienced, but together we will work to achieve the best possible results for your child.
CONFIDENTIALITY
As an Art Therapist for children and adolescents it is difficult to balance the privacy between myself and the client and respecting the parents right for information. A primary goal during treatment will be promoting stronger and better relationship between child and parent, but to build a trusting relationship with my client I need to respect their privacy. It is my policy to provide parents with general information about treatment status. Sharing of specific information to parents will be at the discretion of the child or adolescent. I will not share personal information about you or your child, or his/her life story or what happens in any of our therapy sessions to anyone outside the following three exceptions:

1) If the client requests the release their personal information to an outside party. In this event a Form 14 from the Mental Health Act is required.

2) By Federal Law a therapist is required to: *Report to authorities when they suspect a child is being abused *To comply with a court ordered subpoena.

3) Common Law dictates that it is the responsibility of the therapist to report to authorities when they are privy to plans that a client has to physically harm him/herself or another.
CODE OF ETHICS
In my Art Therapy practice, I follow the Code of Ethics set out by the Canadian Art Therapy Association (CATA) of which I am a member and the College of Registered Psychotherapist of Ontario (CRPO)
THERAPY RATES
Individual Session 50 minutes - $150+HST

TERMINATION OF THERAPY:

The client/or parents are free to terminate at any time.
WHAT TYPE OF FILES DO I KEEP?
I store in a locked environment, personal contact information, progress notes, referral notes, billing documentation and artwork that the client has not taken home for the purpose of: keeping track of appointment dates, important details of the client's life story, what occurs in sessions and financial aspects of the private practice. Products of the therapy session, art, will be kept up to one year at which time they will be photographed, and original items recycled. All files will be kept for seven years after termination of therapy, at which time they will be shredded. When necessary, all files will be moved in a secure manner.
YOUR RIGHTS:
- request, files will be made available to the client within a two-week time period.
- In keeping with your privacy needs, please let me know if, or how, you would like to be greeted if we encounter each other in a public setting.
- I welcome any question or discussion related to your privacy rights.
- All conditions relating to confidentiality mentioned above are in keeping with the Privacy Act of Canada. (A copy may be found on their website www.priv.gc.ca)
At any time, a client may request to look at his or her own files. Upon receipt of a written request.
OBTAINING PARENTAL CONSENT (please check one)*

Married both consentSole custody/guardianship /consentJoint custody/guardianship /consentIt's complicated
PARENT CONTACT INFORMATION:
Guardian 1*

First NameLast Name
Telephone/Cell*

Area CodePhone Number
Email*
example@example.com
Guardian 2

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
I understand and I am in agreement with the above stated conditions.
I*

First NameLast Name
Parent of *

First NameLast Name
consent to participation in Art Therapy facilitated by Claire Nicholls and acknowledge that I have been informed regarding the nature of such therapy for my child or adolescence.
Signature*

Clear
Date*

MonthDayYear
Date
This form requests information about your child which will help us design a treatment plan geared specifically to your child's needs. Please take a few moments to complete the form carefully. We appreciate your time and effort in completing these documents. If you have any questions, let me know. Thank you.
Child’s name

First NameLast Name
Grade
Date of birth (DOB)*

MonthDayYear
Date
Family orientation

Parents togetherSeparated or divorcedBlendedNew partners in household
What are your child's greatest strengths?
Please describe your reason(s) for seeking treatment at this time (Include when the problem started):

Please indicate how the problems are affecting the following areas of you and your child's life:

	Often	Never	Sometimes
Friendships
Peer relations
School performance
Physical health
Family dynamic

Please list other health care professionals currently treating your child:
Issues of concern checklist

Sleep problemsLack of interest in activitiesUnassertiveFatigue/low energyConcentration problemsAppetite/weight changesWithdrawalShort attention spanAggressive behaviorCan't sit stillNot interested in peersPicked on / bullied by peersExcessive worry / fearfulnessForgetful/memory problemsAnxiety or panic attacksSocial fears, shynessSeparation problemsBedwetting / soilingHeadaches, stomachachesOdd beliefs / fantasizingLyingTrouble with authorityRunning awayTruancy (skipping school )Hurting othersSubstance usageSubstance abuseArgumentative / defiantSwearsBlames others for mistakesMorbid thoughtsSuicidal thoughtsSuicidal plans/attemptsMood swingsDepressionChange in activity levelCries easilyTalks excessively / interruptsEasily distractedIrritableDefensiveDifficulty following rulesProblem completing schoolworkNightmaresFrequent tantrumsResistive to changeSchool refusalPerfectionismStealingDestructiveHurting others/ fightingHas no fearShort temperedEasily annoyed / annoys othersAngry/ resentful
Any additional information
Should be Empty:

PARENT CONTACT INFORMATION: