Professional Information Form

"*" indicates required fields

Contact Information

Title

Dr., Mrs., Miss, Mr., Other, etc.

Name*

First Last

Primary Phone*

Note: This phone number will be provided to clients for booking.

What type of line is your primary phone?*

Personal cell

Home

Work

Work cell

Can we text you at this number?*

Yes

Alternate Phone

What type of line is your alternate phone?

Personal cell

Home

Work

Work cell

Can we text you at this number?

Yes

Email*

Note: This email address will be provided to clients for booking.

Alternate Email

Fax

Website/online profile

Counselling Modalities

In Person*

Yes

Telephone*

Yes

Video*

Yes

Name of PIPEDA-compliant video platform*

Are you permitted and wanting to accept clients for video counselling from other Canadian provinces/jurisdictions?

Yes

Please select the provinces/jurisdictions you’re able to see clients in

Check all that apply.

Language(s)

Working Language(s) for Counselling*

Check all that apply.

English

French

Other

Other Working Language(s)

Business Address

Type of Address 1*

Check all that apply.

Billing Address

Office 1

Office 2

Home Office

Company Name*

Address*

Street Address Address Line 2 City Province Postal Code

Office Features

Check all that apply.

Soundproof

Business Licence

Wheelchair Access

Free Parking

Private Entrance

Animals (in home or office re: allergies, phobias)

Would you like to include another address?*

Yes

Type of Address 2

Check all that apply.

Billing Address

Office 1

Office 2

Home Office

Company Name

Address

Street Address Address Line 2 City Province Postal Code

Office Features

Check all that apply.

Soundproof

Business Licence

Wheelchair Access

Free Parking

Private Entrance

Animals (in home or office re: allergies, phobias)

Would you like to include another address?*

Yes

Type of Address 3

Check all that apply.

Billing Address

Office 1

Office 2

Home Office

Company Name

Address

Street Address Address Line 2 City Province Postal Code

Office Features

Check all that apply.

Soundproof

Business Licence

Wheelchair Access

Free Parking

Private Entrance

Animals (in home or office re: allergies, phobias)

Billing/Payment Information

Name showing on your bank account*

VOID Cheque*

Payment is made via Direct Deposit (EFT). Please upload an image of a VOID cheque here for the account you wish to receive deposits to.

Max. file size: 256 MB.

Payment Email

An email receipt will be sent to the email address you indicated above. If a different email address is preferred for these notifications, please note it here.

Do you charge tax?*

Yes

If yes, please Indicate:*

GST#, HST# or QST#

Professional Information

Resume*

Please attach a copy of your resume.

Max. file size: 256 MB.

Professional Designation*

As stated on your registration.

Highest Degree Obtained*

Year Degree was Completed*

Institution Degree was Obtained*

List the regulatory body and/or association(s) of which you are a member in good standing*

Please specify your registration number(s).

Current Registration*

Please attach a copy of your most current registration(s) that includes an expiry date(s).

Drop files here or

Max. file size: 256 MB.

What is your liability insurance coverage amount by incident?*

Practice Insurance*

Please attach a copy of your valid practice insurance that includes an expiry date.

Max. file size: 256 MB.

Availability

Morning (before 12 p.m.)

Check all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Afternoon (12-5 p.m.)

Check all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Evening (after 5 p.m.)

Check all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

If you have multiple office locations, please specify which days of the week you are at each location.

Critical Incident Counselling

Do you have any critical incident stress debriefing (CISD) experience?

Yes

Do you have formal training in CISD?

Yes

Are you able to do CISD sessions at a company location if needed?

Yes

If yes, at which phone number could we contact you in case of an emergency?

Disability Management/Return-to-Work Support

Do you have any experience supporting return-to-work assessments and treatment planning?

Yes

Do you have formal training in supporting return-to-work assessments and treatment planning?

Yes

Are you interested in receiving referrals from Arete for these specialized services?

Yes

Clientele

Clientele Served

Children (0-11)

Teenagers (12-17)

Adults (18+)

Elderly

Couples

Families

Organizations

Services Offered

Addiction Issues

Select all that apply.

Family/Marital/Relationship Issues

Select all that apply.

Medical Issues

Select all that apply.

Acute Illness

Cancer Specialist Support

Chronic Disease/Illness

Family Medical Issue

Fertility issues/pregnancy loss

Pain Management

Terminal Illness

Psychological Issues

Select all that apply.

Work-related Issues

Select all that apply.

Service Areas Not Listed

Indicate any other service areas not listed that you provide services for (if any).

Areas or Populations of Expertise/Specialization

Indicate your areas or populations of expertise/specialization (if any).

Therapy Orientation and Training

If you're using a desktop or laptop and would like to select multiple entries for the questions in this section, hold the Ctrl key (PC) or Command key (Mac) and click on each item (using the mouse/trackpad).

Therapy Orientation

Indicate your major theoretical orientation(s). Select all that apply.

Therapy Training

Indicate the area(s) in which you have had training, or are currently enrolled. Select all that apply.

Any other therapy orientation(s) not listed?

Indicate any other major theoretical orientations you have experience with not listed.

Any other therapy training not listed?

Indicate any other therapy training you have that is not listed.

Are you familiar with the current DSM?

Yes

Are there any Community Mental Health Services or other support services in your area to which you can refer your clients when necessary?

Yes

Training/Group/Employee Facilitation

If you would like to do any training/group facilitation for Arete, please list areas of expertise.

About You

This section is optional and collected only to assist Arete with the matching process. We aspire to have a Network with a wide variety of specializations and lived experiences that reflect the communities we support, and when clients request a counsellor with specific demographic characteristics and/or lived experiences we do our very best to accommodate them. Note that either withholding or providing information in this section will not impact your status as an affiliate.

How would you describe yourself?

Please note your preference

Any other preferred language/clarification you’d like to note?

What pronouns do you use?

What race/ethnicity would you identify yourself as? Check all that apply.

Asian

Black

European/White

Hispanic

Indigenous

Pacific Islander

Don't know

Prefer not to answer

Not listed

Please note your preference

Any other preferred language/clarification you’d like to note?

What’s your religious affiliation? Check all that apply.

Please note your religious affiliation

Any other preferred language/clarification you’d like to note?

What's your birth date?

Is there anything else about your own story and experiences you’d like to share that may help us match clients to you?

Professional Conduct

Have you ever been charged with a criminal offence?*

Yes

Have you ever been convicted of a criminal offence?*

Yes

Are there outstanding complaints against you with a regulatory body?*

Yes

Are there matters involving you currently under investigation by a regulatory body?*

Yes

Are you under orders of discipline by a regulatory body?*

Yes

Has a complaint ever been filed against you with a regulatory body?*

Yes

Have you ever been dismissed from employment, on the grounds of professional misconduct in Canada or elsewhere?*

Yes

Are you currently affected by any physical or mental condition that in any way impairs or limits your ability to practice counselling therapy, with safety, to the public?*

Yes

Do you have any drug, alcohol or other addictions that in any way impair your ability to practice counselling therapy, with safety, to the public?*

Yes

If you answered “yes” to any of the questions above, please provide details.*

Arete Contact

Name of the person you've been communicating with at Arete*

Consent

Date

Professional Information Form

Contact Information

Counselling Modalities

Language(s)

Business Address

Billing/Payment Information

Professional Information

Availability

Critical Incident Counselling

Disability Management/Return-to-Work Support

Clientele

Services Offered

Therapy Orientation and Training

Training/Group/Employee Facilitation

About You

Professional Conduct

Arete Contact

Consent

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