Intake Form

If you do not hear from us within a few business days please check your "junk" folder as sometimes initial messages get filtered as junk!

Thank you!

Name

Age

Names and phone numbers of parents/guardians

For clients under 18 years of age

Reason for Visit

Type of Therapy Please note that Kassey Shier is the only therapist at EBP who offers couples and family therapy

Individual

Couples

Family

List family members who will participate in therapy

Please only fill out this box if you are interested in couples or family therapy

When did these problems start (be as general or as specific as feels comfortable)?

Have you ever been diagnosed with a mental illness?

Yes

If yes, please provide details of diagnoses (including when diagnosed and by whom)

Please list any medical or “physical” problems that you have been diagnosed with or experience

Please list any medications you currently take, and what you take them for

Have you ever been hospitalized for psychological or psychiatric reasons?

Yes

If yes, please provide details (approximate dates, reason, length of stay)

Please tell us about any other mental health professionals you have consulted with in the past (approximate dates, type of professional seen, reason for the consultation, nature of the treatment, outcome of the treatment)

If you have not seen a therapist in the past please write "no"

Have you experienced suicidal thoughts or engaged in suicidal behaviours in the PAST YEAR?

Yes

If Yes, please describe (when, the level of intensity, frequency of thoughts/behaviours)

Have you experienced urges or engaged in acts of self harm (cutting, burning, pinching, hitting oneself, etc) in the PAST YEAR?

Yes

If yes, please describe

Do you struggle with addiction(s)?

Yes

If yes, please describe

What are your goals in therapy? Be as general or specific as you'd like, what are you hoping to get out of therapy?

If you are unsure, that is ok and can be discussed in your first session!

Is there anything else you'd like your therapist to know?

What time of day would you prefer appointments? (please check all that apply)

Morning (9:00-1:00)

Afternoon (1:00-4:00)

Evening (4:00-8:30)

Type of session (please check all that apply) Note: clients must be in the province of Alberta, even if they are attending therapy virtually

Virtual

In person

Email address

Erin, Emily, Kassey or Melanie will reach out to you via email to set up a consultation

Phone number

Please provide a phone number that can receive text messages, a text will be sent in addition to an email (in case emails go to junk folders!)

If you were referred or selected other, who referred you or where did you hear about us?

Your information will be encrypted.