Professional Information Form

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
- No
Alternate Phone
What type of line is your alternate phone?
- Personal cell
- Home
- Work
- Work cell
Can we text you at this number?
- Yes
- No
Email*
Note: This email address will be provided to clients for booking.
Alternate Email
Fax
Website/online profile
Counselling Modalities
In Person*
- Yes
- No
Telephone*
- Yes
- No
Video*
- Yes
- No
Name of PIPEDA-compliant video platform*
Are you permitted and wanting to accept clients for video counselling from other Canadian provinces/jurisdictions?
- Yes
- No
Please select the provinces/jurisdictions you’re able to see clients in
Check all that apply.
- Alberta
- British Columbia
- Manitoba
- New Brunswick
- Newfoundland
- Northwest Territories
- Nova Scotia
- Nunavut
- Ontario
- Prince Edward Island
- Quebec
- Saskatchewan
- Yukon
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
- No
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
- No
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
- No
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
- No
Do you have formal training in CISD?
- Yes
- No
Are you able to do CISD sessions at a company location if needed?
- Yes
- No
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
- No
Do you have formal training in supporting return-to-work assessments and treatment planning?
- Yes
- No
Are you interested in receiving referrals from Arete for these specialized services?
- Yes
- No
Clientele
Clientele Served
- Children (0-11)
- Teenagers (12-17)
- Adults (18+)
- Elderly
- Couples
- Families
- Organizations
Services Offered
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).
Addiction Issues
Select all that apply.
Family/Marital/Relationship Issues
Select all that apply.
Medical Issues
Select all that apply.
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.
Any others not listed?
Indicate any other major theoretical orientations you have experience with not listed.
Therapy Training
Indicate the area(s) in which you have had training, or are currently enrolled. Select all that apply.
Any others not listed?
Indicate any other therapy training you have that is not listed.
Are you familiar with the current DSM?
- Yes
- No
Are there any Community Mental Health Services or other support services in your area to which you can refer your clients when necessary?
- Yes
- No
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.
Gender Identity
If other:
Gender Pronouns
Race/Ethnicity
If other:
Religious Affiliation
If other:
Age
- 20-30
- 31-40
- 41-50
- 51-60
- 60+
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
- No
Have you ever been convicted of a criminal offence?*
- Yes
- No
Are there outstanding complaints against you with a regulatory body?*
- Yes
- No
Are there matters involving you currently under investigation by a regulatory body?*
- Yes
- No
Are you under orders of discipline by a regulatory body?*
- Yes
- No
Has a complaint ever been filed against you with a regulatory body?*
- Yes
- No
Have you ever been dismissed from employment, on the grounds of professional misconduct in Canada or elsewhere?*
- Yes
- No
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
- No
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
- No
If you answered “yes” to any of the questions above, please provide details.*
Consent
Consent*
By completing and submitting this form to Arete, I confirm that all statements are true and complete to the best of my knowledge and belief.

I will advise Arete in a timely manner of any changes to the above information. I consent to the collection of this information and understand the purpose, which is to facilitate a match between a service user (Client) and affiliate (Clinician). This information is collected with the relevant applicable privacy laws, is housed in the secure Arete e-Tera™ database system and is available only to relevant Arete staff. The information enclosed may be discussed indirectly or directly with service users (Clients), but not publicly distributed.
I confirm that all statements in this form are true and complete to the best of my knowledge and belief.*

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Adoption
Aggressive Children
Blended Family
Caregiver support speciality
Child Anxiety
Child Play Therapy
Child/Adolescent
Christian-Based Counselling
Couples/Relationship Difficulties
Domestic Violence
Domestic Violence Speciality
Extended Family
Mediation
Multicultural Couples Counselling
Parent-Child/Teen/Adult Relationships
Parenting Issues
Polyamorous Relationships
School Problems
Separation/Divorce
Sexual Orientation

Acute Stress/Adjustment Disorder
ADD/ADHD Adults
ADD/ADHD Children
ADHD Specialty
Anger
Anxiety
Autism Spectrum Disorder
Autism Spectrum Disorder Specialty
Bipolar
Borderline Personality Disorder Specialty
Boundaries
Bullying
Burnout
CISD
Cultural Issues
Depression
Dissociative Disorders
Eating Disorder
Eating Disorder Specialty
Family Mental Health Issue
FASD
Gender Identity
Gender Transition
Grief/Bereavement
Hypnosis
Indigenous Specialization/Training
Insomnia
Learning/Functioning Issues
2SLGBTQ+
2SLGBTQ+ Specialization
Mood Disorder
Natural Disaster
New Immigrant Stressors
Obsessive Compulsive Disorder
Panic Attacks
Paranoia
Personality Disorder
Phobias
Postpartum
Psychosis
PTSD
Relationship Difficulties
Relaxation
Schizophrenia
Seasonal Affective Disorder
Self-Harm
Self-Esteem
Sexual Abuse
Sexual Dysfunction/Sex Therapy
Spectrum Disorders
Stress
Tourette’s Speciality
Trauma
Veterans population
Victim of Abuse
Visualization

Absenteeism/Tardiness
Anxiety/Stress
Burnout
Career Assessments
Career Issues
Co-Worker Issues
Co-Worker/Peer Relations
Disability absence (STD/LTD)
Downsizing
Harassment
Injury
Management/Supervisor Skills
Organizational Change
Potential Safety Risk
Retirement
Return-to-work
Roles/Duties/Responsibilities
Supervisor Relations
Termination
Vocational/Career Counselling
Work-Life Balance
Work Quality/Quantity

ACT (Acceptance and Commitment Therapy)
Adlerian
Animal Assisted Therapy
Art Therapy
Attachment Therapy
Avatar Training
Biopsychosocial
Bowen Family Systems
Brief Therapy
Cognitive Behavioural Therapy
Clinical Hypnosis
Cognitive Analytic Theory
Conflict Resolution
Couples Therapy
Critical Incident
Dance/Movement Therapy
Dialectical Behaviour Therapy
EMDR
EMDR - Virtual
Eclectic (Various)
Ecotherapy
Emotion-Focused Couple Therapy
Equine-Assisted Therapy
Existential
Family Systems
Feminist
Gestalt
Gottman Marital Therapy
Hakomi
Humanistic
Impact Therapy
Integrated Body Psychotherapy
Intergenerational Trauma
Internal Family Systems (Parts Work)
Interpersonal
Jungian
Mindfulness
Motivational Interviewing
Narrative Therapy
Neuro-Linguistic Programming
Neurofeedback
Neuropsychological Assessment
Pastoral
Perinatal Therapy
Person-Centred
Play Therapy
Prolonged Exposure
Psychedelic-Assisted Psychotherapy
Psychodrama
Psychodynamic/Analytic
Psychoeducation/Insight
Psychoeducational Assessments
Rational-Emotive Therapy
Reality Therapy
Relational
Rogerian
Sandtray
Satir
Schema-Focused Therapy
Self-Regulation Therapy
Sensorimotor Psychotherapy
Sex Addiction Therapy
Sexoanalysis
Short-Term Therapy
Solution-Focused Therapy
Somatic
Spiritual Holistic
Systems/Interactional
Trauma

ACT (Acceptance and Commitment Therapy)
Adlerian
Animal Assisted Therapy
Art Therapy
Attachment Therapy
Avatar Training
Biopsychosocial
Bowen Family Systems
Brief Therapy
Cognitive Behavioural Therapy
Clinical Hypnosis
Cognitive Analytic Theory
Conflict Resolution
Couples Therapy
Critical Incident
Dance/Movement Therapy
Dialectical Behaviour Therapy
EMDR
EMDR - Virtual
Eclectic (Various)
Ecotherapy
Emotion-Focused Couple Therapy
Equine-Assisted Therapy
Existential
Family Systems
Feminist
Gestalt
Gottman Marital Therapy
Hakomi
Humanistic
Impact Therapy
Integrated Body Psychotherapy
Intergenerational Trauma
Internal Family Systems (Parts Work)
Interpersonal
Jungian
Mindfulness
Motivational Interviewing
Narrative Therapy
Neuro-Linguistic Programming
Neurofeedback
Neuropsychological Assessment
Pastoral
Perinatal Therapy
Person-Centred
Play Therapy
Prolonged Exposure
Psychedelic-Assisted Psychotherapy
Psychodrama
Psychodynamic/Analytic
Psychoeducation/Insight
Psychoeducational Assessments
Rational-Emotive Therapy
Reality Therapy
Relational
Rogerian
Sandtray
Satir
Schema-Focused Therapy
Self-Regulation Therapy
Sensorimotor Psychotherapy
Sex Addiction Therapy
Sexoanalysis
Short-Term Therapy
Solution-Focused Therapy
Somatic
Spiritual Holistic
Systems/Interactional
Trauma

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

Consent

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