Intake Form

 

*Date:

*Date: :: (For example: Jan 4, 1008)

*Completed By:

*Completed By: :: Please enter your name.

 

Demographic Information

 

*Name of Client(s):

*Date of Birth:

*Address:

*Phone:

*Phone: :: (xxx) xxx-xxxx

Message OK?

Yes
No

Cell Phone:

Cell Phone: :: (xxx) xxx-xxxx

Message OK?

Yes
No

*Email Address:

*Email Address: :: example@example.com

Message OK?

Yes
No

Referral Source:

*Marital Status

*Next of Kin:

*Relationship:

*Phone:

Therapist / Specialty Requested:

*Availability:

Mornings
Afternoons
Evenings
Other

If 'other' please explain:

*Payment Method:

ICBC
CVA
WCB
EAP
Ext Medical
Self
Other

If 'other' please explain:

 

Presenting Concerns

 

*What areas are you hoping to address in counselling?

*Why would it be helpful to address those areas?

*What are you hoping that counselling can provide for you in those areas?

*Are you experiencing any suicidal thoughts?

Yes
No

If yes, please explain:

Please enter the characters you see in the box:   

Please enter the characters you see in the box: :: Sorry, but this is essential to block spammers. ENTER THE DARK LETTERS ONLY!!