Client confirmation form

 Client ID*:  Assessed by*:  Assessor’s e-mail*:  Assessed  Year*:—2014201520162017201820192020 Month*: —010203040506070809101112 Day*:01020304050607080910111213141516171819202122232425262728293031 Dept.*: —SPTIPTPInternRoster Modality*: —IndividualCoupleFamilyCombined  Client home language*:  —EnglishFrenchBilingual E/FSpanishHebrewItalianRussian Level of education*: —NoneElementaryHigh SchoolCEGEPUniversity  Number in Family:*   Dependants*: Sliding scalePrivate  Family income*: —$0 – $21,999$22,000 – $26,999$27,000 – $31,999$32,000 – $36,999$37,000 – $41,999$42,000 – $51,999$52,000 – $61,999$62,000 – $71,999$72,000 – $81,999$82,000 – $91,999>$92,000Not required for private clients  Session fee

Client file closure form

  Client ID*:   Form filled by*:   Filler’s e-mail*:   Last interview: *  Year: —201520162017201820192020  Month: —010203040506070809101112  Day: —01020304050607080910111213141516171819202122232425262728293031  Initiated by*: —ClientTherapistBothOtherInternship end  Final?:* YesNo   Number of sessions*:   Goal of therapy 1:     Therapist evaluation 1:   1 – Much less than expected2 – Less than expected3 – As expected4 –