Intake Form
Please fill in the information below prior to your first session. Information provided on this form is protected as confidential information.
* Required
Email address
*
Your email
Name:
*
Last Name, First Name
Your answer
D.O.B.:
*
MM
/
DD
/
YYYY
Gender:
*
Female
Male
Prefer not to say
Other:
Street Address:
Your answer
City:
Your answer
Postal Code:
Your answer
Telephone (Primary):
*
e.g. (519) 111-1111 **Please indicate if it is okay to leave a message**
Your answer
Emergency Contact:
Please state family, friends, etc.
Your answer
Email Address:
*
**Please indicate if it is okay to send and initial email**
Your answer
Marital Status:
*
Married/Common Law
Single (Never Married)
Separated or Divorced
Widow/Widower
Other:
Presenting Concerns:
*
Please check all that apply
Concerned with personal use
Concerned with use of Spouse/Partner
Concerned with use of Child/Youth
Not Applicable
Alcohol
Drugs
Gambling
Gaming
Internet Use/Social Media
Pornography
Sex
Intimacy
Shopping
Stress
Anxiety
Concerned with personal use
Concerned with use of Spouse/Partner
Concerned with use of Child/Youth
Not Applicable
Alcohol
Drugs
Gambling
Gaming
Internet Use/Social Media
Pornography
Sex
Intimacy
Shopping
Stress
Anxiety
Referral Source
How did you learn of this service? Please check all that apply
Self-Help Group (AA, NA, CA, GA, SA, SAA etc.)
Mental Health Professional/Counsellor
Web Browser Search Engine
Health Care Provider (Doctor, Nurse Practitioner)
Friend/Family
Treatment Mandated By:
*
None - Personal Decision
Condition of Family
Condition of Employer
Condition of School
Other:
Have you been diagnosed with a Mental Health problem by a qualified Mental Health Professional?
If yes, what was your most recent diagnosis?
Your answer
Have you ever been prescribed medication for a Mental Health problem?
If yes, please list:
Currently
Within Last 12 Months
Within Lifetime
Yes
No
Currently
Within Last 12 Months
Within Lifetime
Yes
No
Have you previously received any type of Mental Health services (Psychotherapy, Counselling, Social Work, or Psychiatric services, etc.)?
If yes, please list:
Currently
Within Last 12 Months
Within Lifetime
Yes
No
Currently
Within Last 12 Months
Within Lifetime
Yes
No
Are there any other health related concerns that I should be aware of in order to best support your goals?
*
Your answer
What would you like to accomplish out of your time in the therapy?
*
Your answer
What are your preferred dates and time slots for the first session.
*
Your answer
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