Counseling Intake Form

Nest Therapy Client Intake Form

The information on this form is secure and will only be viewed by your therapist. All sections are required to be completed to the best of your ability. If you have any questions or concerns about completing this form, please contact Allison Wood at halitherapist@gmail.com. You may not be seen if your form is incomplete or not submitted before your first appointment.
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
Preferred method of contact to leave a private message (please check all that apply):

E-mailHome PhoneCell Phone
How did you hear about Nest Therapy?
Relationship Status
Client's Identified Gender:

FemaleMaleOther
Do you have any children?

YesNo
If yes, how many; age; gender (please free to include deceased as well)
Employment
Type of employment:
Primary Care Provider Name e.g. Doctor, Nurse Practitioner and phone number:
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 and what you hope to gain from this experience?
Have you seen a mental health professional in the past e.g. clinical social worker, registered counsellor, psychologist?

YesNo
Reason for attending therapy in the past:
Are you currently experiencing any suicidal thoughts or have in the last few weeks or 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 primary healthcare provider e.g. doctor or nurse practitioner.
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 the full fee. Another appointment will not take place until your balance is paid in full. Please review my website for information on my fees.
Should be Empty:

Nest Therapy Client Intake Form

Emergency Contact Information

Medical History

Mental Health History

**Fee Policy: