Client Intake Form
*Required fields. If there are questions you prefer not to answer or you do not know the answer, then leave them blank.
*Client Name
First Name
Last Name
*Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*Date of Birth
-
Month
-
Day
Year
Date
Ethnicity
*Home Phone
Format: (000) 000-0000.
*Cell Phone
Format: (000) 000-0000.
*Email
example@example.com
*Preferred Method of Contact
Home Phone
Cell Phone
E-mail
*Relationship Status
Please Select
Single
Married
Divorced
Widowed
Family?
Spouse?
Children?
*Emergency Contact Information
Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Relationship
Insurance Information
Name of Insurer
First Name
Last Name
Insurer Phone Number
Format: (000) 000-0000.
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Mental Health History
Previous Therapy?
Yes
No
When? Reason for therapy?
What worked? What didn't work?
Any treatment from medical mental health professionals?
Yes
No
Any mental health diagnosis/concerns?
Are you on any medication?
History of depression? Family history of depression?
Do you have self-harming behaviour including suicide? Please explain.
Present or past addictions?
Present or past trauma?
*Why are you seeking counselling now?
Any other information you want your therapist to know?
*Preferred Method of Counselling
Virtual
In-Person
Telephone
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Submit
Appointment
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