Client Intake Form There was an error trying to submit your form. Please try again.Part 1: Personal Information First Name * This field is required. Last Name * This field is required. Date of Birth * This field is required. Preferred Phone * This field is required. May I leave a message at this number? * Yes No This field is required. Email Address * This field is required. Emergency Contact Name This field is required. Phone Number This field is required. Physician’s Name This field is required. Phone Number This field is required.Part 2: Marital Status Marital Status Single Married Separated Divorced Widowed Childred Yes No Part 3: Please Complete The Following Questions What are the main concerns/issues that you wish to discuss in therapy? * This field is required. How long have you had these concerns? * This field is required. Do certain things help (massage/meditation/prayer/talking/artwork/exercise)? * This field is required. Have you attended counselling/therapy before? * Yes No This field is required. What did you find most helpful? Part 4:For the following questions, please scale your level of concern on a scaled of 0-10: 0 = no concern; 10 = serious concern: Medical problems or the use of medication? This field is required. Alcohol or drug abuse? This field is required. Impact of substance-use on relationships? This field is required. Abuse or violence in your life? This field is required. Thoughts of self-harm? This field is required. Thoughts of suicide? This field is required.Part 5: Therapeutic Goals What is essential for your therapist to know about you as a person? What is your desired take-away from therapy? Submit There was an error trying to submit your form. Please try again.If the above form does not work, please download the following file, fill out and bring it to your first appointment.Client Intake FormDownload
