Child and Teen-- Burden Bearers Counselling Grande Prairie
Confidential Intake Interview Information Form
Child's / Teen's Personal Information
Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Preferred Name(s) (if different)
Birthdate
*
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
The Phone Number is a
Home Phone
Cell Phone
Work Phone
Other
Occupation(s)
Parent or Guardian Information
Name of Parent/Guardian 1
*
First Name
Last Name
Parent/Guardian 1's Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Parent/ Guardian 1's Phone number
*
-
Area Code
Phone Number
The Phone Number is a
*
Home Phone
Cell Phone
Work Phone
Other
Parent/Guardian 1's Email
*
example@example.com
Parent/ Guardian 1's Occupation
Is there another parent/ guardian for this child/teen?
No
Yes, We live at the same address.
Yes, We live at different addresses.
Name of Parent/Guardian 2
First Name
Last Name
Parent/Guardian 2's Address
Street Address
Street Address Line 2
City
Province
Postal Code
Parent/ Guardian 2's Phone number
-
Area Code
Phone Number
The Phone Number is a
Home Phone
Cell Phone
Work Phone
Other
Parent/Guardian 2's Email
*
example@example.com
Parent/ Guardian 2's Occupation
Relationship Status - Select all
*
Single
Dating
Other
Dating- Whom
*
Dating- How Long
Have you had any previous counselling?
*
Yes
No
Where/ When/ and With who was the counselling?
Referral Information
How did you hear about this office?
Facebook
Webpage
Google
Doctor
Brochure
EAP
Church
Radio
Other
Back
Next
Questionnaire of Concerns:
Medical Issues and Medications:
*
Depression (If yes, when did it start):
*
Anxiety (If yes, when did it start):
*
Stresses:
*
Sleep problems:
*
Memory / Concentration concerns (Explain):
*
Eating Concerns (If yes, what kind):
*
Addictions (If yes, what kind ie. Substance, Gambling, etc):
*
Thoughts or plans of self-harm:
*
Abuse
*
Past
Present
None
Unknown
Sexual
Emotional
Physical
Racism and/or Cultural Discrimination
Other
Sexual / Identity Concerns:
*
Losses (If yes, What are they):
*
Family Environment (Supportive or problematic?):
*
Parental Issues:
*
Work Situation (Supportive or problematic?):
What resources or supports do you have in your life? (Community, faith, sports, friends, family, etc.):
*
What do you hope to accomplish in counselling?
*
Financial Commitment
I will pay the standard counselling fee of $130/hour either before or directly after my child's counselling session.
*
Yes
No
I will be paying using health insurance
I wish to speak to office staff about eligibility for reduced fee sessions. I understand that eligibility is assessed based on acceptable proof of household gross annual income.
Yes
No, I will pay the standard rate of $130/hour.
I will pay my child's sessions through direct billing by Burden Bearers to my insurance company.
Yes
No, I will pay the standard rate of $130/hour up front and submit my receipts to my insurance company.
Submit
Should be Empty: