Counselling Intake Form
Who is seeking counseling?
Myself
My Child
Myself and My Partner
Other
Personal Information of Person Seeking Counselling
Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Client's Age
*
Gender
*
Male
Female
Transgender
Non-Binary
Prefer not to say
Other
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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Next
Caregiver A's Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Preferred Method of Contact
*
Phone
Email
Any Method
Relationship with the counseling person
*
Parent
Grandparent
Guardian
Friend
Other
Marital Status between Caregivers:
*
Married
Separated
Divorced
Single
Widowed
Is your address same with the counseling person?
*
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Next
Caregiver B's Information
(If applicable)
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Preferred Method of Contact
*
Phone
Email
Any Method
Relationship with the counseling person
*
Parent
Grandparent
Guardian
Friend
Other
Is your address same with the counseling person?
*
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Next
Partner's Information
Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Transgender
Non-Binary
Prefer not to say
Other
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Is their address same?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Back
Next
Counselling Information
Main Concerns for Therapy or Assessment:
*
Is there anything else you would like us to know before their first appointment?
*
Is there a specific therapist you are requesting to see?
*
Anh Ambler
Rhonda Monts
Kristianna McGonigal
No Preference
Preference for appointment availability:
*
Mornings
Early Afternoon (12PM)
Late Afternoon (After 3PM)
Evening (After 5PM)
Are you looking to utilize coverage through a third-party or your employer?
*
Yes
No
*If responding yes, what is the insurance company?
ASEBP/Blue Cross
Greenshield
Manulife
Canadalife
iA Financial Group
Desjardins Insurance
Sunlife
Other
*If responding No, are you willing to submit tax documents to prove income to quality for our sliding scale fee for those who have a gross household income under $140,000?
Please Select
Yes
No
Referral Information
How did you hear about us?
*
Internet Search
Website
Family or friend
Psychology Today
Facebook
Other
Date of Submission
-
Month
-
Day
Year
Date
Submit
Should be Empty: