Focused Counselling Intake:
Client #1 Name
*
First Name
Last Name
Client #1 D.O.B
*
-
Month
-
Day
Year
Date
Client #1 Gender
*
Type of therapy requested
*
Individual
Couples
Family
Client #2 Name
First Name
Last Name
Client #2 D.O.B
-
Month
-
Day
Year
Date
Client #2 Gender
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number H:
*
Phone number C:
*
Phone number W:
Can we leave a voicemail with the phone numbers provided?:
*
Yes
No
Are you under the age of 18 years old?:
*
Yes
No
If you are under the age of 18, please list your parental guardian's names:
Martial status:
*
Single
Common-law
Separated
Divorced
Married
E-mail
*
example@example.com
How did you hear about us?
*
Social Media
School
Website
Door Hanger
Google
Friend
Physician
Other
What is the household’s monthly net income?
*
How many people are supported by this income?
*
Insurance coverage:
*
Yes
No
If Yes, list Insurance Company:
Policy #:
Member ID:
Are you the Primary Member of this plan?
Yes
No
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:
Therapy preference:
*
In-person
Teletherapy (Video/Phone call)
No preference
Payment method:
*
Credit Card
PayPal (Teletherapy)
Debit Card (In-person only)
Cash (In-person only)
Specific requests:
Presenting concern #1:
*
Presenting concern #2:
Emergency contact:
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Thank you!
We will be in touch with you in a few days.
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