Client Intake Form

Client Intake Form (Individual)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Preferred Method of Contact

E-mailMobile PhoneTextAll of the above
Emergency Contact Information

*required in case of an medical emergency or if there is an intent to harm oneself or others
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Relationship to you
Medical History
Please check all the apply

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
Do you use alcohol?

NoDailyWeeklyLessFormer User
Do you use tabacco?

NoDailyWeeklyLessFormer User
Have you been convicted of drug related charges?

YesNo
Please explain the circumstances
Are you currently taking prescription medication?

YesNo
Prescribing Doctor's Name

First NameLast Name
Prescribing Doctor's Phone

Area CodePhone Number
Clinic details :
Family History : (provide brief background information eg. medical, personal)
Mental Health History
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
Therapist Name

First NameLast Name
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Reasons for seeking counselling?
Goals for counselling - What do you expect? What do you hope to achieve?
Additional comments or concerns
*Your signature below indicates that the information you have provided in this form is accurate and completed best to your knowledge. You have read our Confidentiality Privacy Policy, Terms and conditions and you consent to participate in counselling.
Date

DayMonthYear
Date
Signature

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Client Intake Form (Individual)

Emergency Contact Information

Medical History

Mental Health History