New Client Intake Form
Client Name
*
First Name
Middle Name
Last Name
Date of Birth (YYYY-MM-DD)
*
Preferred Name or Nickname
Gender
*
Please Select
Male
Female
Non-Binary
Other
Preferred Pronouns:
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Primary Phone
*
xxx-xxx-xxxx
Alternative Phone
xxx-xxx-xxxx
Can I leave voicemail messages at the above numbers?
Yes
No
E-Mail
*
How did you hear about me? (Please specify website or referral name/source)
Insurance Provider's Name
Group Number
ID Number
Annual Coverage / Limits
Have you been in therapy before?
Yes
No
If yes, when and for how long/# of sessions?
Please elaborate on reasons you sought therapy for in the past & if you found therapy helpful:
Professionals you currently see:
Medical Doctor
Psychiatrist
Counsellor
Life Coach
Chiropractor
Naturopath
Massage Therapist
Other
Name of family doctor & phone number:
Your current physical health is:
Good
Fair
Poor
Please elaborate:
Your current mental health is:
Good
Fair
Poor
Please elaborate:
Do you experience suicidal thoughts?
Yes
No
Please elaborate:
Marital Status:
Single
Married
Divorced
Widowed
Separated
Domestic Partner
Problems experiencing with intimate relationships:
Do you have children?
Yes
No
If yes, names and ages of children:
Problems experiencing with children:
Work Status
Employed
Unemployed
Retired
Disabled from Work
Student
Employer / School
Occupation / Area of Study
Problems experiencing with work/school:
Was it your idea or someone else's to seek out counselling?
In your words, what lead you to seek counselling at this time?
What have you tried so far to cope with/help your current difficulties?
What are your greatest strengths?
In 3 months from now if counselling is helpful, how will you know? What will have changed? What will be different?
How motivated are you to make changes in your life, on a scale from 0-10?
0
1
2
3
4
5
6
7
8
9
10
Not Motivated At All
Extremely Motivated
0 is Not Motivated At All, 10 is Extremely Motivated
What would you like in a counsellor? (e.g. someone who is warm, directive, supportive, gives homework, etc.)
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