Counselling Intake Form

Counselling Intake Form

Your Practitioner: Annie Baxter
Client Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Marital Status
Email
example@example.com
Employment
Home Phone
Cell Phone
Preferred Method of Contact

E-mailHome PhoneCell Phone
Is the individual seeking counselling under 18? Please note that if you are seeking treatment for more than one individual, please fill in a separate form.
If the primary individual seeking counselling/coaching is under 18 please fill in the Family Consent Form (one per family) as well. Thankyou.
Under 18 client : Full Name

Legal NamePrefered Name
Date of Birth

MonthDayYear
Date
Emergency Contact name and number:
Gender

FemaleMaleNon-binaryPrefer not to sayOther
If other, please comment below if you would like to identify your gender.
Please list Address if it is different from caregiver filling out this form.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who do they live with? (Parents, guardians, other relatives, foster care, etc.)
Siblings (Names and Ages)Is there anyone else living in your home? (Describe relationship and age)
Parent/Guardian Name
Phone Number Guardian
Please enter a valid phone number.
Parent/Guardian Name
Phone Number Guardian
Please enter a valid phone number.
Name

First NameLast Name
Medical History
Please check all the apply

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
Have you been convicted of drug related charges?

YesNo
Please explain the circumstances
Are you currently taking prescription medication?

YesNo
Have you had any surgeries in the past 5 years?

YesNo
Please specify:
Family history

AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal DiseaseOther
Mental Health History/Goals
Why you are seeking treatment?
What are you goals?
Any significant family changes recently (divorce, separation, death, etc.)?
Please share anything you feel is important for me to know in order to best support You, including any emotional, behavioral, triggers, fears, social, family, school, or mental health challenges, recent life changes, trauma history, or goals you have for growth and wellbeing.
Have you seen a counsellor, psychologist, psychiatrist or other mental health professional before?

YesNo
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
Mount Willow Counselling – Consent & Agreement Summary
Voluntary Participation

I choose to participate in counselling voluntarily.
I understand counselling is focused on wellness and personal growth, and it is not a substitute for medical or emergency mental health treatment.
Confidentiality & Privacy

All sessions are confidential except if:

There is risk of harm to self or others
Disclosure is required by law
Online sessions are offered through secure, HIPAA-compliant platforms (Psychology Today). While every effort is made to protect privacy, no online system is 100% secure.

Technology & Safety: I will attend online sessions in a private space.
If technical issues arise, the counsellor may follow up by phone to maintain continuity of care.

Cancellation Policy: 24 hours’ notice is required to cancel or reschedule a session.
Cancellations with less than 24 hours’ notice or missed sessions may be billed at the full session rate.

Transition to Coaching: If goals are more action-focused, coaching can be integrated into counselling.
If my needs change, the counsellor may recommend switching between counselling and coaching.

Practitioner Statement:
I am a Master Practitioner Clinical Counsellor- Provisional, under supervision), Level 1 EFT practitioner, certified Life Coach, Insight Coach ICF accreditied, NLP and mindfulness-trained, and a Therapeutic Play Practitioner (RMPTI).
I am committed to providing a safe, supportive, and trauma-informed environment in every session.

By signing this form, I acknowledge that I have read and understood this agreement.
For Online Youth Counselling sessions, please provide a number we can use to complete our session if our connection is lost at any point.
Please enter a valid phone number.
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
signature

Clear
Guardian signature

Clear
Should be Empty:

Counselling Intake Form

Medical History

Mental Health History/Goals