Consent and Intake Form

Please complete this consent and intake form before your scheduled MENDSKY session. Your therapist may need to review this information before your appointment.

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Name *

First

Last

Email *

Phone Number *

Emergency Contact Number

Preferred Language

Appointment Date *

of / Physical

Appointment Date / Time

Date

Time

Assigned Therapist *

Physical Location at Time of Session *--- Select Choice ---Ontario, CanadaBritish ColumbiaCanada AlbertaCanada QuebecCanada Other Canadian province or territoryUnited StatesOutside Canada / United States

Please select where you will be physically located at the time of your online session.

Consent to Online Therapy *

• I understand that MENDSKY is an online platform that helps connect clients with independent therapists and counsellors.
• I understand and agree to receive online therapy/counselling services from my assigned therapist through the MENDSKY platform using secure online communication tools.
• I understand that my therapist is responsible for clinical care, professional judgment, informed consent for treatment, and therapy-related obligations.
• I understand that online sessions may involve privacy and technology risks, including internet disruption, device or software issues, and unauthorized access if I do not use a private space, secure internet connection, and secure device.
• I understand that MENDSKY is not an emergency or crisis service. If I am in immediate danger or need urgent help, I should contact local emergency services.
• I understand that MENDSKY may collect, use, store, and share limited personal information as needed for account creation, booking, intake, communication, payment support, platform administration, and record-keeping.
• I understand that my information may be shared with my assigned therapist for therapy-related purposes.
• I understand that confidentiality has legal and professional limits, including situations involving serious risk of harm, legal requirements, or mandatory reporting obligations.
• I understand that therapist availability may depend on my physical location and the therapist’s licence, registration, professional rules, and permitted jurisdiction of practice.
• I confirm that the information I provide is accurate to the best of my knowledge, including my current location at the time of receiving services.
• I consent to the collection, use, storage, and limited disclosure of my information for the purposes described above.
• I understand and agree to the MENDSKY Intake Consent.
• I understand that MENDSKY is not an emergency or crisis service.
• I consent to the collection, use, storage, and limited disclosure of my information for the purposes described above.

Typed Signature *

By typing my full name, I confirm that I have read, understood, and agree to the consent terms above.

Date *

Submit