KV Psychology & Wellness Clinic Intake Questionnaire
The information collected in this questionnaire is considered confidential and is only used to determine which service and clinician is best suited for your needs. Once we review this information, we will contact you to book an appointment.
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1. What is your first and last name?
2. Who are you completing this form for?
Myself (go to question 5)
Someone else - my child, friend or spouse (go to question 3)
Myself and other individuals for couples or family sessions (go to question 3)
3. What is the first and last name(s) of the individual(s) attending the session
4. What is their relationship to you?
5. What are the ages and date(s) of birth of all those involved in the session?
6. If the individual seeking services is 15 years of age and under, do they live with both parents? (this information is needed for parental consent to services)
Yes (go to question 8)
No (go to question 7)
7. What are the parent/guardian names involved with custody of the child?
8. Name of the school attending (if applicable)
9. Provide a brief description on the reason for seeking services.
10. If you've looked at our therapist bios, do you have a preference of who you would like to see? You can list a couple of options if you would like.
11. What time of day is best suited for your schedule?
Morning Appointments (8:30 am to 12 pm)
Afternoon Appointments (12 pm to 4 pm)
Evening Appointments (4 pm to 8 pm)
12. What is the best phone number for us to contact you to book a session?
13. Can we leave a confidential voicemail on this number?
14. What is your email address?
15. How would you like to receive appointment reminders?
Both text and email
16. Do you have a health insurance plan?
Yes (go to question 16)
No (go to question 18)
17. Who is your health insurance provider?
18. What type of professional is covered in the psychology services portion of your plan?
Licensed Counselling Therapist
Registered Social Worker
I don't know
19. How did you hear about our clinic?
20. Additional details
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This form was created inside of KV Psychology and Counselling Clinic.