Psychotherapy Intake Form

Psychotherapy Intake Form for services from JGGillis Counselling

Any information provided below is confidential and will not be shared with any other party. Some restrictions apply in rare circumstances.
Personal Information
Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Marital Status
Primary Care Provider
Family doctor or walk-in clinic professional
Referring Care Provider
Psychiatrist or social worker or ???
Email
example@example.com
Cell Phone

Area CodePhone Number
Home/Work Phone

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Method of Contact

Authorization
- I hereby understand that my personal details provided above are subject to disclosure for legal purposes and I authorize the specific facility to gather all the necessary details for my application to ensure the safety of both parties.

- I acknowledge that some or all of my personal information may be shared with the appropriate authorities if I (1) am a danger to myself or others, (2) disclose current child abuse, (3) disclose that a member of the medical community has assaulted me, or (4) disclose that there is a vulnerable person at risk.

- I agree with my counsellor's cancellation policy that I must inform my counsellor of any absences in advance, or I will be charged for half of my usual fee.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Psychotherapy Intake Form for services from JGGillis Counselling