Counseling Intake Form

Nest Therapy

Client Intake Form: The information on this form is secure and will only be viewed by your therapist.
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Home Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Methods of Contact (please check all that apply):

E-mailHome PhoneCell PhoneOkay to leave a private message?Ok to send texts to your cell phone (only related to appointments)?
How did you hear about Nest Therapy?
Relationship Status
Do you have a child/children living or deceased?

YesNo
If yes, how many, age and gender:
Employment
Type of employment:
Primary Care Provider e.g. Doctor, Nurse Practitioner :
Primary Care Provider Phone Number :
Do you have Private Insurance? I can provide you with a receipt for reimbursement if your provider is other than Blue Cross.

YesNo
Blue Cross Policy #
Identification Number #
Emergency Contact Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Medical History
Are you currently taking prescription medication?

YesNo
If yes, please indicate what medications or supplements you are taking that may be of relevance e.g. antidepressant, sleeping aid, birth control etc.
Please list any health issues, surgeries or illnesses, current or past that may be of relevance:
Mental Health History
Reason you are seeking treatment?
What are you hoping to gain from this experience?
Have you seen a mental health professional in the past e.g. clinical social worker, counsellor, psychologist?

YesNo
What was that experience like for you? Are there things that worked or didn't work?
Reason for seeking help in the past :
Are you currently experiencing any suicidal thoughts?

YesNo
If you answered "yes" to the above question, please comment:
Have you experienced any suicidal thoughts in the the last few weeks/months?

YesNo
If you've answered "yes" to the above question, please comment:
**If you are experiencing a mental health emergency and believe you are at imminent risk of harming yourself or others, please contact the services below:

1)Mobile Crisis Intervention: 902.429.8167 or 1.888.429.8167 (toll free)

2)Your local emergency room

3)Your family doctor
Additional comments or things that would be helpful for your therapist to know about you?
Date

MonthDayYear
Date
**Fee Policy:

Please be advised that you are required to cancel your appointment 24 hours in advance to avoid paying 50% of my full fee. If you do not show for your appointment and/or do not provide suitable notice, you will be responsible for paying the full session fee before another appointment can occur. Please review my website for information on my fees.
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform

Nest Therapy

Emergency Contact Information

Medical History

Mental Health History

**Fee Policy: