AOH Intake Form

Date*

Date

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Date of birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship Status:*

Is it ok to email you?

YesNo

Is it ok to leave a voicemail for you?

YesNo

How did you find us?

Word of mouthWebsite searchSocial mediaOther

Have you had previous counselling?*

YesNo

If yes, how long ago?

Reasons for this appointment today / concerns that you have:*

What are your goals of counselling?

List any medications you are currently on:

Confidentiality and Session Observation:

Occasionally, sessions may be observed for supervision or training purposes (ie. training a new clinician) to improve the quality of care provided. Any information discussed during sessions, including those that are observed, will be kept private and secure.

No information will be shared with anyone outside of this circle without the client’s written permission, except in the following circumstances:

If ordered by the court to testify or release records.
If the client is a victim or perpetrator of abuse
If there is reason to believe that the client is threatening harm to themselves, someone else, or the property of another

In all of these situations, the therapist is required by law to report to the appropriate authorities or take reasonable steps to prevent harm.

Please check the box below to indicate consent:

I consent to having my sessions observed occasionally for supervision or training purposesI do not consent to having my sessions observed

Date*

Date

Signature*

Intake Form

Demographic Information:

Counselling History:

Counselling Agreement:

Confidentiality and Session Observation: