Self-Intake Screening Web

Intake Form

This form is designed to help us understand your current needs, preferences, and any relevant background information so we can connect you with a counsellor. The details you provide allow us to match you with a provider who is best suited to support your specific concerns and goals.All information submitted through this form is kept confidential and is used solely for the purpose of coordinating your counselling care and improving your experience with the service.
What is your full name? If you are seeking couple's or family counselling, please include first and last name of all individuals.
Which Union/Company/Municipality/Association do you belong to?
Are you the Employee/Member or a Dependent/Family Member?

Other
What age range do you fall into? (If counselling is being requested for a child, please use the child's age, if counselling is being requested for a couple or family, please select all appropriate age ranges.)
What is your date of birth? (If counselling is being requested for a child, please use the child's date of birth. If couples or family counselling is being requested, please use one date of birth.)

MonthDayYear
Date
What is your full address

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number:
Email Address:
Are you comfortable with messages being left by phone or email?

Other
Please indicate your gender identity:

Other
Are you seeking legal, financial, or nutritional consultation?
Which area of legal consultation are you looking for?
(e.g., family law, real-estate law, criminal law, will contracts, etc.)
Which area of financial consultation are you looking for?
(e.g., budgeting, investments, tax planning, retirement, debt management, etc.)
Which area of nutritional consultation are you looking for?
(e.g., weight loss, Healthy Eating, dietary restrictions, Medical conditions, etc.)
Are you seeking a referral for counselling?
Are you seeking a referral for counselling?
Please provide a reason for seeking support (main presenting issue, e.g., anxiety, depression, etc.)
Are you experiencing any thoughts of wanting to harm yourself or others?

Yes (Please list any emergency contacts you are comfortable contacting in the case of any imminent danger to yourself or others. If you have a plan of intent please call 911)
Are you concerned about an abusive relationship you may be involved in?

Yes (Please explain. If you feel like you are in imminent danger please call 911)
Are you concerned regarding children or vulnerable adults in need of protection?

Yes (Please explain, including if any authorities have been involved)
Have you had any past treatment for mental health related issues? This may include counselling/therapy, psychiatric care, medication, support groups, or other mental health services.

Yes (please share any details you’re comfortable providing)
Do you work in a safety-sensitive position (e.g., operating forklift, machinery, vehicle)?

Yes (Explain)
Are you experiencing any alcohol or drug use issues?

Yes (Please include a brief description)
What substance(s) are being used and briefly describe the concern?
Frequency of use: Average number of days per week?
Average amount used per day?
Date of last use

MonthDayYear
Date
Any withdrawal symptoms (irritability, shakiness, difficulties thinking, hallucinations)?

Yes (explain)
Any past treatment for alcohol or drug use?

Yes (explain)
Have you engaged in counselling through MembersHealth Inc. in the past?

Yes (Would you like to be referred to the same therapist as before?)
What is your preferred mode of counselling? (Please select at least 2 options)
What is your preferred availability for counselling appointments? Please select all that apply.
Do you have any therapist preferences?

Other
Requested Therapist Name

First NameLast Name
Requested Therapist Email
example@example.com
Requested Therapist phone
Please enter a valid phone number.Format: (000) 000-0000.
What is your primary language?
How did you hear about us?

Other
Please note that you will be contacted within 2-3 business days by a MembersHealth Clinical Team Member or a therapist for booking. Should you need any further information or should you later need in-the-moment support, please call 1-800-484-0152 and you will be connected with the appropriate contact.

For more information, in-the-moment support, or confidential leadership assistance, call 1-800-484-0152.
All personal information you provide through this form, including within 'Health, Wellness & Beyond,' is kept strictly confidential and will never be shared with your employer under any circumstances.
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Intake Form