Intake Form
Please fill in the information below prior to your first session. Information provided on this form is protected as confidential information.
Email address *
Name: *
Last Name, First Name
D.O.B.: *
MM
/
DD
/
YYYY
Gender: *
Street Address:
City:
Postal Code:
Telephone (Primary): *
e.g. (519) 111-1111 **Please indicate if it is okay to leave a message**
Emergency Contact:
Please state family, friends, etc.
Email Address: *
**Please indicate if it is okay to send and initial email**
Marital Status: *
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
Referral Source
How did you learn of this service? Please check all that apply
Treatment Mandated By: *
Have you been diagnosed with a Mental Health problem by a qualified Mental Health Professional?
If yes, what was your most recent diagnosis?
Have you ever been prescribed medication for a Mental Health problem?
If yes, please list:
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
Are there any other health related concerns that I should be aware of in order to best support your goals? *
What would you like to accomplish out of your time in the therapy? *
What are your preferred dates and time slots for the first session. *
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