Nest Therapy
Client Intake Form: The information on this form is secure and will only be viewed by your therapist.
Client Name
*
First Name
Last Name
Preferred pronoun e.g. she/they
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Home Phone
*
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Preferred Method of Contact
E-mail
Home Phone
Cell Phone
Okay to leave a private message?
How did you hear about Nest Therapy?
Relationship Status
Single
Married
Divorced
Widowed
Common-Law
N/A
Do you have a child/children?
Yes
No
If yes, age and gender:
Employment
Employed
Unemployed
Disabled
Retired
Student
Maternity/Parental Leave
Stay at Home Parent
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.
Yes
No
Blue Cross Policy #
Identification Number #
Emergency Contact Information
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Medical History
Are you currently taking prescription medication?
Yes
No
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
Why 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?
Yes
No
What was that experience like for you? Are there things that worked or didn't work?
Reason for seeking help in the past :
Additional comments or things that would be helpful for your therapist to know about you?
Date
-
Month
-
Day
Year
Date
**Fee Policy:
Please be advised that you may be charged the full fee if you do not cancel your first or follow-up appointment within 24 hours. If you do not show for your appointment and do not provide notice, you will be responsible to pay for the full session before another appointment can occur. Please review my website for information on my fees.
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