New Client Intake Form

First Name

Preferred Name

If Different*

Middle Name:

Last Name:

Date of Birth

Age

Gender

Preferred Pronouns

(If applicable) School:

Grade:

If completing forms for a child under the age of 19 (mature minor), we require the permission from both parents for the child to engage in our services unless the court order states otherwise.

Sole Custody:

Joint Custody:

Cell Phone:

May we leave a message at this number?

Yes

Is there anyone else we can leave a message with at this number?

Home Phone:

May we leave a message at this number?

Yes

Is there anyone else we can leave a message with at this number?

Work Phone:

May we leave a message at this number?

Yes

Is there anyone else we can leave a message with at this number?

Email:

May we contact you via email?

Yes

Primary Address:

City/Town:

Postal Code:

Secondary Address (If Applicable):

City/Town:

Postal Code:

Emergency Contact:

Phone Number:

Relationship to You:

Are you currently, or likely to be, involved in a lawsuit?

Yes

What do you want to work on in therapy/what do you want to have assessed?

Any previous experience with counselling/therapy? If so, Why?

Who referred you to us?

Do you have any relatives, friends or coworkers that currently attend our clinic?

Name of your family doctor:

Phone:

Please list any current illnesses/medical conditions:

Please list all the people who currently live with you (if client resides at more than one address please indicate information for both):

Address #1:

Name(s):

Age(s):

Relation(s) to you:

Address #2:

Name(s):

Age(s):

Relation(s) to you:

Insurance Company to which you plan to submit receipts, if applicable:

Do we have your permission to share information about your therapy with the following person(s), in order to facilitate services that are being provided to you?

The referral source named above:

Yes

The family doctor named above:

Yes

*Please note: The client or an authorized representative, may rescind or amend the authorization in writing at any time prior to the expiration, except where action has been taken in reliance on the authorization.

Would you like to receive text reminders for your appointments?

Yes No

Disclaimer: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Signature

Date

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