Counselling Intake Form
Private Paying Clients
Client Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Post Code
Date of Birth
*
-
Day
-
Month
Year
Date
Marital Status
Please Select
Single
Married
Divorced
Widowed
Email
*
example@example.com
Employment
Please Select
Employed
Unemployed
Disabled
Retired
Student
Primary Care Provider
Referral Name
First Name
Last Name
Preferred Session Format
Please Select
Face to Face (White Rock Community Centre)
Phone
Online
Mobile Phone
Format: 0000-000-000.
Alternative Phone Number
Format: 0000-000-000.
Preferred Method of Contact
E-mail
Mobile Phone
Alternative Phone
Emergency Contact Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Post Code
Phone Number
*
Format: 0000-000-000.
Relationship
*
History
What concerns or goals would you like support with? (e.g. anxiety, family issues, emotional regulation, trauma)
Has the person attending counselling seen a counsellor, psychologist or other mental health professional in the past? If so, please provide details below.
What do you expect from this counselling?
Is there anything you'd like your counsellor to know before your first session?
Will anyone else be present or nearby during your sessions? If yes, who?
Medical History
Please check all the apply
None
Allergies
Anemia
Angina
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Benign Prostatic
Hypertrophy
Blood Clots
Cancer
Cerebrovascular Accident
Cronary Artery Disease
COPD (Emphysema)
Crohn's Disease
Depression
Diabetes
Gallbladder Disease
GERD (Reflux)
Hepatitis C
Hyperlipidemia
Hypertension
Irritable Bowel Disease
Liver Disease
Migraine Headaches
Myocardial Infarction
Osteoarthritis
Osteoporosis
Peptic Ulcer Disease
Renal Disease
Seizure Disorder
Thyroid Disease
Other
Do you use tobacco?
No
Daily
Weekly
Less
Former User
Do you use alcohol?
No
Daily
Weekly
Less
Former User
Caffeine use?
No
Daily
Weekly
Less
Former User
Have you been convicted of drug related charges?
Yes
No
Please explain the circumstances
Are you currently taking prescription medication?
Yes
No
Medications currently in use:
Are there any known safety concerns or risks (e.g. history of aggression, current legal matters) If so, please describe briefly.
Family history
Adopted
Alcoholism
Allergies
Asthma
ArthritisBlood Disease
CAD (Heart Attack)
Cancer
CVA (Stroke)
Depression
Developmental Delay
Diabetes
Eczema
Hearing Deficiency
Hyperlipidemia (High Cholesterol)
Hypertension (High Blood Pressure)
Irritable Bowel Disease
Learning Disability
Mental Illness
Tuberculosis
Obesity
Osteoarthritis
Osteoporosis
PVD
Renal Disease
Other
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Day
-
Month
Year
Date
Signature
Submit
Submit
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