INTAKE FORM

INTRODUCTION:

Gender :

May I leave a message? :

May I leave a message? :

May I email you? :

*Please note: Email correspondence is not considered to be a confidential medium of communication.

Marital Status

At Home?

HEALTH INFORMATION :

Physician

Psychiatrist

Are you currently attending or have attended any groups or other forms of therapy? (AA, Al-Anon, Individual, Couples, Family Therapy, etc.) Please indicate.

HEALTH INFORMATION :

Please indicate your highest level of education

Are you currently employed?

CHURCH, COMMUNITY AFFILIATION :

Do you consider yourself to be spiritual or religious?

FAMILY HISTORY :

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member in the space provided (self, brother, sister, father, mother, uncle, etc.)

Alcohol Abuse

Drug Abuse

Gambling Addiction

Pornography/Sex Addiction

Attention Deficit Hyperactive Disorder (ADHD)

Anxiety

Depression

Suicide Attempts

Domestic Violence

Eating Disorders

Obesity

Obsessive Compulsive Behaviour

Schizophrenia

What was the happiest or best period of your life? (describe)

What was the most difficult or tragic period of your life? (describe)

SELF ASSESSMENT :

What are the main problem(s) as you see it?

What have you done about your problem(s) in the past or recently?

What can the counsellor do to help you? (e.g. compassionate listening, help you understand your situation better, provide strategies….)

How motivated do you feel you are to solve your problem(s)?

How will you know when your problem(s) are better?

How do you see yourself?

How do other people see you?

How would you like to be seen?

Is there any other information that you think I should know?

POLICIES :

FEES AND PAYMENT: Fees are payable at the time of each visit, unless other arrangements have been made. You are responsible for payment regardless of third party involvement. One month’s notice will be given for any increase.

CANCELLATIONS: Appointments are scheduled for 1 hour, 1.5 hour and 2 hour blocks of time. A specific time during the week has been reserved for you. If you must cancel due to illness, please notify me as soon as possible. Should you need to cancel for any other important reason, 48-hour notice is required, otherwise you will be charged for the session. Advance notice gives me time to reschedule and allow someone on the waitlist to be seen.

TELEPHONE CALLS & EMAILS: I check my confidential email and voicemail, daily, (but frequently on holidays). For emergencies, please call 911.

CONFIDENTIALITY: Counselling is confidential except where limited by Canadian law. These exceptions include situations that involve child, elder, or dependent adult abuse or if a client is a danger to him or herself or others. Written permission is otherwise needed to disclose any information to a third party. When working with children and adolescents, it is my policy to regard everything said in session as confidential except where noted above. I will encourage the child or adolescent to disclose to the parent information regarding substance abuse, sexual activity, or other behaviour that places him or her at risk.

I understand and agree to the guidelines listed above, to the statement of confidentiality, and to paying all the charges in full at each meeting.