Counseling Intake Form Intake Form Client Information Name: * Date of Birth Gender: Address: City: Province: OntarioQuebecNew BrunswickPrince Edward IslandNova ScotiaNewfoundland and LabradorManitobaSaskatchewanAlbertaBritish ColumbiaNorthwest TerritoriesYukonNunavut Postal code: Phone Number: Email: * Emergency Contact Name: Relationship: Phone Number: Referral Information How did you hear about us? If referred, by whom? Presenting Issues Please briefly describe the reasons for seeking counseling: Medical History Do you have any current or past medical conditions? YesNo If yes, please explain: Are you currently taking any medications? YesNo If yes, please list: Mental Health History Have you ever received counseling or therapy before? YesNo If yes, please explain: Have you ever been diagnosed with a mental health condition? YesNo If yes, please specify: Substance Use Do you use any substances (alcohol, drugs, etc.)? YesNo If yes, please explain: Family Background Please describe your family structure: Are there any family issues or dynamics you would like to address? Goals for Counseling What are your goals for counseling? Consent I consent to treatment and understand the confidentiality policies of this practice. I consent to treatment and understand the confidentiality policies of this practice. Signature signature keyboard Clear Date: Captcha Submit If you are human, leave this field blank. Δ
