Adult Intake Form

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Dropdown

Name

First

Last

Address

City

Postal Code

Phone Number(s)

Phone Number (Primary)

Secondary Phone Number (Optional)

Date Of Birth (yyyy-mm-dd format)

Age

Gender

Birthplace

City

Province

Marital Status

Home situation; Please list the people you are living with spouse/partner, children, relatives, friends, and so forth. Please also list any children who are not living with you.

1. First Name

1. Sex (M/F)

1. Age

1. Relationship

1. Occupation

1. Health Concerns

2. First Name

2. Sex (M/F)

2. Age

2. Relationship

2. Occupation

2. Health Concerns

3. First Name

3. Sex (M/F)

3. Age

3. Relationship

3. Occupation

3. Health Concerns

Current Occupation and Employer

Emergency Contact – Name

Emergency Contact – Telephone

Emergency Contact – Address

Education – Highest Grade attained

Other formal education / degree(s) (If applicable)

PRESENTING CONCERN

Describe the major problem(s) you would like help with

When and how did this problem develop? Were there any unusual pressures or stressors in your life at the time that this problem developed?

Have you seena professional counsellor previously? If so, please indicate when and with whom?

Please list current medication including vitamins or suppliments.

If you could change one thing about your circumstances, what would it be.

Have you ever attempted suicide or are feeling suicidal now?

If you have attempted suicide or have ever been bospitalized as a result of a suicide attempt, please list dates and hospitalizations.

How would you describe your parents while growing up? (Easy going, Authoratative, etc)

Number of siblings

Previous marriages/common-law relationships/significant relationships (if applicable)

Please list any current or previous health problems (including surgeries, hospit stays, back pain, etc) that continue to cause you pain.

Please list any work stressor(s) you are experiencing

How would you describe the number of friends or social supports you have?

How much alcohol do you consume during an average week? (e.g., # of beers, ounces of hard liquor)

Birthplace Contact 2.

Recreational Drugs/Herbal Supplements/Other (please specify type and frequency):

Office Policies

Our Goal is to collaborate with our clients to provide meaningful help as effectively and efficiently as possible in a compassionate, non-judgmental client centered environment. Successful counselling requires commitment, openness, and honesty from clients. We may introduce various tools and interventions if we believe they will facilitate the client’s treatments goals. However, the client always has the right, and is encouraged to communicate if they would prefer to try another strategy.

Confidentiality:

All communication between yourself and your counsellor is held in strict confidence and will not be released to anyone without your written consent. The limit to confidentiality includes legal requirements to report circumstances wherein a client states an intention to harm themselves or another, in cases of child, elder, or vulnerable persons abuse. In order to provide the best care possible, your counsellor may consult with a supervisor or other professional, wherein the same rules of confidentiality apply.

Benefits and Risks:

The counselling process is intended to provide relief from distressing symptoms, introduce new coping skills and problem-solving strategies, and provide a new perspective on challenging issues. Personal growth and change can be a stressful and difficult process for many individuals where an increased awareness of your patterns, feelings, behaviors, and values could lead to stressful life changes.

Cancellation, Payment, and Termination Policy:

We require 24-hour notice for canceled appointments. Any missed appointments or last-minute cancellations are billed at the regular fee. Sessions are required to be paid at the time of the session. Payments can be made by cash, credit card or etransfer. The following session will not be undertaken until the previous session has been paid in full. Services can be terminated by either the client or the counsellor. It is best for both parties to participate in the termination process as this provides an opportunity for constructive feedback, integration of work to date, and appropriate referrals, where necessary. Electronic audio or video recordings are strictly prohibited, with the exception of training purposes. If recording is required for training purposes, written consent will be obtained prior to the session.

Fees:

We do not direct bill insurance companies. However, we are registered with the Canadian Counselling and Psychotherapy Association, Member # 10010417, as a Certified Canadian Counselor, which is covered by many insurance companies.

Service Type: Individual Counselling 60 min session $120

I certify and agree the above information is correct. I have read and understand the above statements and agree to treatment and to pay the stated fee.

Signature

Clear Signature

Date

Phone Number(s)

Birthplace

PRESENTING CONCERN

Office Policies

Give Us A Call

Send Us A Message

Office Location

Hours of Operation: