Intake Form
Motivating Change Counselling
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Home Phone
*
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Preferred Method of Contact
*
E-mail
Home Phone
Cell Phone
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Number of Children
Profession
Emergency Contact Information
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship
*
Medical History
History of alcohol and/or drug use?
*
Yes
No
If yes, how often?
Any previous medical diagnosis?
*
Yes
No
Please state medical/mental health diagnosis?
Are you currently taking prescription medication?
*
Yes
No
If yes, name of medication(s)?
Why are you seeking treatment and what are your goals?
*
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
*
Yes
No
Therapist Name
First Name
Last Name
Are you receiving any other service/support from any other community agencies? If so, please name agency/services.
*
How did you hear about us?
*
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
Date
Signature
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