Intake Form (Adult)

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Last name

Phone number

Date of birth

Email address

Address

Insurance

Please Note: In order to best understand your specific plan and coverage, we recommend calling your insurance company and speaking directly with a customer service representative to determine coverage for outpatient therapy (code 90837) in an outpatient OFFICE setting (code 11). Ask about your copay and deductible. Unfortunately, due to liability reasons, we no longer determine coverage on the client's behalf. We are happy to provide you with a form to help guide this process. When calling, ask if Karen Canada is in network even if you are being scheduled with another counselor. Some of the counselors bill under my number. As long as I am in network, they will be able to bill.

Medical History

Have you been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for your visit

Please briefly comment on anything you checked above.

Please let us know how we can help. What would you like to get out of counseling? What area of your life are you hoping will improve as a result of counseling?

Notice about Letters, Recommendations, Form Completion:

Our primary service is the provision of clinical counseling. In some cases, a recommendation or form completion may naturally emerge from this process as part of the therapeutic work.

To preserve the integrity of the counseling profession, please understand that we do not provide recommendations for school, work, housing, disability or other purposes, nor do we complete forms, except for established clients with whom we have developed a working clinical relationship.

We recognize that requests for letters, recommendations, or form completion often feel urgent. However, this policy ensures that any statement we provide is grounded in professional knowledge of a client’s needs, abilities, and history. This protects both the client and the counselor by ensuring that all documentation reflects accurate, clinically-informed observations.

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