Focused Counselling Intake Form

Focused Counselling Intake:
Please ensure that your contact information is entered correctly (ie: email address) as we cannot be held liable if your information goes to an outside party due to an error made while entering such information on the intake form.

Thank you.

Please Note: If multiple people would like individual therapy please fill out seperate intake forms.
Name of person completing Form*

First NameLast Name
Legal Name (if different from above)
Type of therapy requested*

IndividualRelationshipFamily
- How many people will be attending therapy*
  
  1 person2 people3 people4 people or more
- Client #1 Name*
  
  First NameLast Name
- Legal Name (if different from above)
- Client #1 Phone Number
- Client #1 Email*
- Verify Email*
  example@example.com
- Client #1 D.O.B*
  
  MonthDayYear
  Date
- Gender
- Pronouns
  
  He/HimShe/HerThey/ThemOther
- Client #2 Name
  
  First NameLast Name
- Legal Name (if different from above)
- Client #2 Phone Number:
- Client #2 Email:
- Gender
- Pronouns
  
  He/HimShe/HerThey/ThemOther
- Client #2 D.O.B
  
  MonthDayYear
  Date
- Client #3 Name
  
  First NameLast Name
- Legal Name (if different from above)
- Client #3 Phone Number
- Client #3 Email
- Gender
- Pronouns
  
  He/HimShe/HerThey/ThemOther
- Client #3 D.O.B
  
  MonthDayYear
  Date
- Client #4 Name
  
  First NameLast Name
- Legal Name (if different from above)
- Client #4 Phone Number:
- Client #4 Email:
- Gender
- Pronouns
  
  He/HimShe/HerThey/ThemOther
- Client #4 D.O.B
  
  MonthDayYear
  Date
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Can we leave a voicemail with the phone numbers provided?:*
  
  YesNo
- Is the person who will be receiving therapy under the age of 18 years old?:*
  
  YesNo
- Please enter both parental gaurdians names and contact information below
- Parent 1 Name:
- Parent 1 Email:
  example@example.com
- Parent 1 Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Parent 2 Name:
- Parent 2 Email:
  example@example.com
- Parent 2 Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Please select the option that best describes your current parenting arrangement
  
  Child resides with both parents.Child resides with one parent and there is a shared custody agreement in place.Child resides with one parent and there is a sole custody agreement in place.Child resides with one parent and there is no custody agreement (sole or shared)in place.
- Please Note: If there is a shared custody agreement in place both parents will need to sign consent forms prior to therapy.
- Martial status:*
  
  SingleCommon-lawSeparatedDivorcedMarried
- What is your highest level of education?
  
  Some High School or lessHigh School graduateSome College or Technical schoolCollege or Technical school graduateSome UniversityUniversity undergraduate degreePost graduate degree/Masters/PhDPrefer not to say
- What is your current employment status?
  
  Full-timePart-timeCasualRetiredOn Disability LeaveFull-time StudentUnemployed and looking for emplymentUnemployed and not looking for employmentPrefer not to sayOther
- What is the household’s gross annual income?*
- How many people are supported by this income?*
- Are you paying more than 30% of your gross income toward housing?
  
  YesNo
- Are you Insured through Non- Insured Health Benefits (NIHB):*
  
  YesNo
- NIHB Client ID Number:
- Insurance coverage:*
  
  YesNo
- Please list Insurance Company:
- Policy #:
- Member ID:
- Are you the Primary Member of this plan?
  
  YesNo
- If you answered No, please enter the Primary Member’s Full Name, Date of Birth and ID#.
- Secondary Insurance Company (If applicable)
- Policy #:
- Member ID:
- Which designation does your insurance company cover? Please inquire if you don't know before proceeding with your claim.
  
  Masters of Social Work (MSW)Provisional PsychologistRegistered Psychologist (R.Psych)Canadian Certified Counsellor (C.C.C)
- Sex Assigned At Birth (for Direct Billing purposes only):
- Therapy preference:*
  
  Teletherapy (Video/Telephone)In-Person
- Specific requests:
- Presenting concern #1:*
- Presenting concern #2:
- Emergency contact:*
  
  First NameLast Name
- Emergency contact's relationship to client:
- Emergency contact's phone number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Emergency contact's email address*
  example@example.com
- How did you hear about us?*
  
  Social MediaSchoolWebsiteDoor HangerGoogleFriendPhysicianPsychology TodayOther
- Do you consent to receive text appointment reminders prior to your scheduled appointment?
  
  YesNo
- Do you consent to receive Client Satisfaction and other Program related surveys from Vantage Community Services?
  
  YesNo
- Thank you!
  
  Once we receive your intake form, you will receive contact from our Intake Department within 10 business days via Email. Please ensure you check your Junk Mail folder in case our email gets redirected there.
- Should be Empty:

Focused Counselling Intake:

Thank you!