Counselling Intake Form
Who is seeking counseling?
Myself
My Child
Myself and My Partner
My Family
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.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
*
First Name
Last Name
Relationship to Counselling Person
*
Please Select
Parent/Guardian
Grandparent
Partner
Spouse
Friend
In-laws
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Personal Information of Family Members Seeking Counselling
(Minor or Adult Children)
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
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
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
If you have additional children, please put their name(s), preferred name, DOB, Client Age, Gender below:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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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.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Method of Contact
*
Phone
Email
Any Method
Relationship with the counseling person
*
Parent
Grandparent
Guardian
Friend
Other
Marital Status between Caregivers:
*
Married
Separated
Common-Law
Divorced
Single
Widowed
Other
Do you have sole custody/guardianship or medical decision making rights and willing to provide documentation (otherwise consent from the other parent may be required)?
Yes
No
Is your address the same as the address provided?
*
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.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Method of Contact
*
Phone
Email
Any Method
Relationship with the counseling person
*
Parent
Grandparent
Guardian
Friend
Other
Is your address the same as the one provided?
*
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
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.
Format: (000) 000-0000.
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
Relationship to Counselling Person
*
Please Select
Parent/Guardian
Grandparent
Partner
Spouse
Friend
In-laws
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Counselling Information
Main Concerns for Therapy or Assessment (please only share what you are comfortable with):
*
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
Liam Ganton
Preference for appointment availability:
*
Mornings
Early Afternoon (12PM)
Late Afternoon (After 3PM)
Evening (After 5PM)
Weekend
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: