Adult Intake Questionnaire
Updated January 2025 - **Please be aware that Amanda's rates will be changing from $220/hour to $235/hour effective March 1, 2025.  Direct billing is still available for most insurance companies.
Sign in to Google to save your progress. Learn more
Email *
Date: *
MM
/
DD
/
YYYY
Therapist Requesting: At this time, Amanda is not accepting any new clients.  Please contact Rachel Brushett, Office Manager at rachel.brushett@icloud.com before completing this questionnaire.  If you have already spoken to Rachel, please go ahead and complete the intake. *
Required
Name: *
Date of Birth *
MM
/
DD
/
YYYY
Age: *
Family Physician:
Psychiatrist (if applicable)
Email (for billing purposes) *
Phone Number: *
Alternate Phone Number:
Who referred you to our services? *
What would be the main reason you are seeking psychological services? *
Are you currently seeing a counsellor? *
Have you had counselling before, if yes with who and what was the outcome? *
Are there any current court proceedings that you are involved in that could affect your counselling? If there is, Amanda will not get involved until all court proceedings are complete. *
Any other information you would like to share?
**Please know that we are able to direct bill most insurance companies, should you have one.  However, we always recommend that you contact your insurance company prior to your first appointment to find out 1) if direct billing is available 2) how much you are eligible for annually 3) how much you are eligible for per session.  This way there is no surprises.  If you have an insurance company, please advise which insurance company it is. If you do not have one, please just write "none" *
Member's Name of Insurance Company
Member's Date of Birth of Insurance Company
MM
/
DD
/
YYYY
Plan/ID #
Group #
Consultation Agreement - Please click the link below and take the time to read through our consent at the bottom of the page prior to your first appointment so that if you have any questions or concerns, that you can bring them up to your therapist.
https://www.solfocpsy.ca/services 
Thank you for taking the time to fill this out, it really gives us a snapshot of what you would like help with for your appointments.
Should you need to contact our office you can do so by calling (403) 504-9777 or via email at rachel.brushett@icloud.com
Submit
Clear form
Never submit passwords through Google Forms.
GoogleForms
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google.