Fertility Intake

To disclose & exchange information with your fertility treatment providers.

Fertility treatment

I am requesting your consent so that after our counselling session, I can provide a letter to your fertility doctor outlining that you have completed the counselling requirement and that you are ready to proceed with treatment.

I work under Psychologist, Dr Stephanie Bot. As an associate, Dr. Bot supervises my work and helps me guide my practice. If you ever wanted to speak to her, just let me know. She’s lovely!

Thanks for choosing me to help you along your journey.

Fertility Intake

Your Full Name *

Your Address *

Your Birthdate *

Your State *

Your Email *

Your Country *

Emergency Contact

Please add a Contact Name & Phone Number in Case of Emergency.

Emergency Contact Person *

Emergency Contact Phone *

Fertility Clinic *

Your Doctor *

When did you begin fertility treatment? *

Duty to Warn:

Do you agree to disclose and exchange information with your fertility treatment providers?

Inform a potential victim of violence if the client discloses an intention to inflict harm.

Inform the emergency contact if a client shows intention to end his/her life or inflict self-harm.

Release a client's file if it is subpoenaed by a court of law.

Inform the appropriate authorities in any actual or suspected child or elder abuse.

Consent to Agree *

Yes

No

Fertility Intake

Fertility treatment

Informed Consent Form