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.
Name*

First NameLast Name
Legal Name (if different from above)
Client #1 Phone Number:
Client #1 Email:
Client #1 D.O.B*

MonthDayYear
Date
Gender
Pronouns

He/HimShe/HerThey/ThemOther
Type of therapy requested*

IndividualRelationshipFamily
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
Are you under the age of 18 years old?:*

YesNo
If you are under the age of 18, please list your parental guardian's names:
Martial status:*

SingleCommon-lawSeparatedDivorcedMarried
E-mail*
example@example.com
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
Insurance coverage:*

YesNo
If Yes, 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/Phone call)In-person
Payment method:*

Credit CardPayPal (Teletherapy)Debit card or cash (In-person)
Specific requests:
Presenting concern #1:*
Presenting concern #2:
Emergency contact:*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How did you hear about us?*

Social MediaSchoolWebsiteDoor HangerGoogleFriendPhysicianOther
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!

Please note that currently it can be up to 2 weeks to be contacted to book your initial appointment. We appreciate your understanding!
Should be Empty:

Focused Counselling Intake:

Thank you!