Focused Counselling Intake:
Name
*
First Name
Last Name
Legal Name (if different from above)
Client #1 D.O.B
*
-
Month
-
Day
Year
Date
Pronouns
He/Him
She/Her
They/Them
Other
Type of therapy requested
*
Individual
Couples
Family
Client #2 Name
First Name
Last Name
Legal Name (if different from above)
Pronouns
He/Him
She/Her
They/Them
Other
Client #2 D.O.B
-
Month
-
Day
Year
Date
Client #3 Name
First Name
Last Name
Legal Name (if different from above)
Pronouns
He/Him
She/Her
They/Them
Other
Client #3 D.O.B
-
Month
-
Day
Year
Date
Client #4 Name
First Name
Last Name
Legal Name (if different from above)
Pronouns
He/Him
She/Her
They/Them
Other
Client #4 D.O.B
-
Month
-
Day
Year
Date
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 annual 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:
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 Psychologist
Registered Psychologist (R.Psych)
Canadian Certified Counsellor (C.C.C)
Sex Assigned At Birth (for Direct Billing purposes only):
Please Select
Male
Female
Therapy preference:
*
Teletherapy (Video/Phone call)
In-person
Payment method:
*
Credit Card
PayPal (Teletherapy)
Debit card or cash (In-person)
Specific requests:
Presenting concern #1:
*
Presenting concern #2:
Emergency contact:
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Do you consent to receive Client Satisfaction and other Program related surveys from Vantage Community Services?
Yes
No
Thank you!
We will be in touch with you in a few days.
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