Veridian Wellness Clinics Psychology/Therapy Intake Form (Adult)

Emergency Assistance

If this is an emergency, call:

Suicide Crisis Line: 811
Medical Emergency: 911

Client Information

First name

Last name

Date of birth

Self-Identified Gender

Biological Sex

Male

Female

Contact Information

Phone Number

Email address

Address

Can we contact you by email and/or leave a voicemail for you?

Yes No

If no, please specify how you prefer us to contact you.

Please select which service(s) you are seeking at Veridian Wellness Clinics

Short-term DBT Skills Training

Short-term ADHD/Executive Functioning Skills Training

Psychological Rapid Access Assessment

Psychiatric Rapid Access Assessment (no provincial health insurance, or Quebec health insurance)

If you have MSP or another provincial health insurance (besides Quebec), you will require a GP referral for this service

Combined Psychiatric/Psychological ADHD Assessment (no provincial health insurance, or Quebec health insurance)

If you have MSP or another provincial health insurance (besides Quebec), you will require a GP referral for this service

I'm not sure

If you are unsure about what services you are seeking at VWC, please briefly describe your inquiry.

Please briefly describe your current challenges and/or what prompted you to seek services at VWC.

Please briefly describe your goals or what you hope to get out of services at VWC.

What appointment format do you prefer?

Video Call

In-person

All in-person appointments take place at our office in Burnaby, BC

Phone Call

Please note assessments MUST be done via video call or in-person appointments.

Insurance

Do you have extended health benefit coverage (ex. SunLife, Canada Life)?

Yes No

Do you know if you extended health benefits provider provides coverage for services provided by clinicians under the supervision of a Registered Psychologist? Please note the supervising Registered Psychologist's registration number will appear on your receipt.

Yes

I'm not sure

If you do not currenlty have an active MSP or health insurance from another province/territory, please briefly describe why/your current situation.

Medical History

Have you previously received any mental health support (e.g., seeing a psychiatrist, therapist, taking prescription medications for mental health)?

Yes No

If yes, what mental health support or treatment have you received? Please provide a brief description.

If you have received therapy, please indicate what type of therapy (e.g., CBT, trauma processing). Please indicate when you received this therapy or if it current.

Please list any mental health disorders you have already been diagnosed with, when you were diagnosed, and by who.

Please list all medications you are currently taking.

Is there anything else regarding your personal history that we should be aware of?

Thank you for completing our secure self-referral form. Our administrative staff will reach out to you via email or phone call within 48 business hours.

How did you hear about Veridian Wellness Clinics?

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