INTAKE FORM

Kindly complete and submit this Form before your first visit. The information you provide will be retained for your records and will be held in strict confidence. You may leave a question blank if you prefer to discuss it directly with your counsellor. You can also access this Form in PDF Format here.

Client's Name*

First Last

Phone*

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Treatment History

Are you currently receiving psychiatric services, professional counseling or psychotherapy elsewhere?

No
Yes

Have you had previous psychotherapy?

No
Yes

Name

Are you currently taking prescribed psychiatric medication (antidepressants or others)?

No
Yes

If yes, please list

Prescribed by:

Health and Social Information

Do you currently have a primary physician?

No
Yes

If yes, who is it?

Are you currently seeing more than one medical health specialist?

No
Yes

If yes, please list:

When was your last physical?

Please list any persistent physical symptoms or health concerns e.g. chronic pain, headaches, hypertension, diabetes, etc.:

INTAKE FORM

Step 1 of 4

Treatment History

Health and Social Information

OCCUPATIONAL INFORMATION

RELIGIOUS/SPIRITUAL INFORMATION

FAMILY MENTAL HEALTH HISTORY

PAGES

RESOURCES

WHAT CLIENTS SAY