Intake Form
Initial Client Profile. To provide Shari with some background information to help save time in the initial session.
First Name *
Your answer
Last Name *
Your answer
Gender *
Address *
Your answer
City, Province/State *
Your answer
Postal Code/Zip Code *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Best EMAIL address to reach you at *
Your answer
Phone Number incl. area code *
Your answer
Can I leave a message at this number? *
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Marital Status *
Children including Name/Age/Relationship
Your answer
Counselling History (include approx. year, # sessions, and what treatment was sought for)
Your answer
Briefly describe your previous counselling experience(s): positive/negative, what you liked/disliked, etc.
Your answer
What do you want to address in counselling? State your main concerns. *
Your answer
Are you currently on medication? *
Please list current medications you are taking
Your answer
Is there a concern about alcohol use, drug abuse, or overuse of prescription drugs? *
Please Explain:
Your answer
How concerned are you about violence? 0 being none, 10 being the most concerned *
Please Explain:
Your answer
Is there any concern about suicide? *
Please Explain:
Your answer
Anything else you would like Shari to know before you start counselling?
Your answer
How did you hear about Shari Derksen?
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