Forms

Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.

Name

First Middle Last

Name of parent/guardian (if under 18 years):

First Middle Last

Birth Date

Gender

Male
Female

Marital Status:

Please list any children/age:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

May we leave a message?

Yes
No

May we leave a message?

Yes
No

Email

May we email you?

Yes
No

*Please note: Email correspondence is not considered to be a confidential medium of communication

Referred by (if any)

General Information

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

Yes
No

Previous therapist/practitioner:

Are you currently taking any prescription medication?

Yes
No

Please list:

Have you ever been prescribed psychiatric medication?

Yes
No

Please list and provide dates:

Health Information

GENERAL HEALTH INFORMATION

MENTAL HEALTH INFORMATION

Please list any specific health problems you are currently experiencing:

How would you rate your current sleeping habits?

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?

What types of exercise to you participate in?

Please list any difficulties you experience with your appetite or eating patterns:

Are you currently experiencing overwhelming sadness, grief, or depression?

Yes
No

If yes, for approximately how long?

Are you currently experiencing anxiety, panic attacks, or have any phobias?

Yes
No

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain?

Yes
No

If yes, please describe:

Do you drink alcohol more than once a week?

Yes
No

How often do you engage recreational drug use?

Are you currently in a romantic relationship?

Yes
No

If yes, for how long?

On a scale of 1-10, how would you rate your relationship?

What significant life changes or stressful events have you experienced recently:

Family Health Information

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.)

Alcohol/Substance Abuse

Yes
No

List Family Member

Anxiety

Yes
No

List Family Member

Depression

Yes
No

List Family Member

Domestic Violence

Yes
No

List Family Member

Eating Disorders

Yes
No

List Family Member

Obesity

Yes
No

List Family Member

Obsessive Compulsive Behavior

Yes
No

List Family Member

Schizophrenia

Yes
No

List Family Member

Suicide Attempts

Yes
No

List Family Member

Additional Information

Are you currently employed?

Yes
No

If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current work?

Do you consider yourself to be spiritual or religious?

Yes
No

If yes, describe your faith or belief:

What do you consider to be some of your strengths?

What do you consider to be some of your weaknesses?

What would you like to accomplish out of your time in therapy?

Payment and Cancellation Policy

Payment should be made at the end of each session for the agreed upon rate. The fee for each session (approx. 1 hr.) is $200. Payment can be made in Cash, Cheque, or Credit Card. Please understand that if you fail to cancel a scheduled appointment, we cannot use this time for another client. We will need to bill you for the entire cost of your missed appointment. Cancelation must be made no less than 24-hours prior to the appointment unless it is due to an emergency. Thank you for your consideration and understanding regarding this important matter.

Signature*

Clients Signature (Client’s Parent/Guardian if under 18)

Date*

Todays Date

Terms*

By pressing submit you are agreeing to the terms above

Phone

This field is for validation purposes and should be left unchanged.

Intake Form

General Information

Health Information

Family Health Information

Additional Information

Payment and Cancellation Policy