New Client Intake Form

New Client Intake Form

This document is strictly confidential. It is designed to assist us in preparing for your first, one-on-one meeting, and will only be seen by our office personnel.
Name*

First NameLast Name
Pronouns (optional)
Date of Birth:*

MonthDayYear
Date
Age:*
Sport/ Activity*
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*
Ok to text?*
E-mail*
example@example.com
If under 18, Guardian's Name

First NameLast Name
Guardian's Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Guardian's Phone Number
Ok to text?
Guardian's E-mail
example@example.com
Other Guardian's Name

First NameLast Name
Other Guardian's Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Other Guardian's Phone Number
Ok to text?
Other Guardian's E-mail
example@example.com
Is there anything you would like me to know with respect to your race, culture, or heritage?
Do you have any special needs/ disabilities/ diagnoses that you would like us to know?
Is there anything you would like me to know with respect to your identity or gender?
Do you have any mental health diagnoses or suspected mental health diagnoses?*
If yes, please provide more details.
Have you ever attended for psychotherapy/ counselling before?*
If yes, please provide more details (e.g. therapist's name, reason for attending).
Please tell me at least one good thing about yourself.*
What are the things you want to discuss & why?*
What are you hoping to achieve from attending coaching/ psychotherapy (i.e. your goals)?*
What do you consider to be the greatest obstacle in achieving your coaching/ psychotherapy goals?*
Is there anything else you would like me to know?
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
I acknowledge that the above information is correct to the best of my knowledge.*
Should be Empty: