INTAKE FORM

Please take a few minutes to complete the information below. If you are unsure of the information please leave it blank and we can discuss during our session.

BASIC INFORMATION
First Name: / MI: / Last Name:
DOB: DD/MM/YYYY / Current Age: / Gender:
Address:
City: / Province: / Postal Code:
Phone: OK to Leave Message:
☐ Yes ☐ No / Email:
Emergency Contact: / Phone:

TREATMENT HISTORY

1. Have you received psychotherapy in the past? ☐ No ☐ Yes,

If yes, Name of the Provider: ______

If yes, what was helpful: ______

2. Are you currently receiving psychiatric services, professional counselling or psychotherapy elsewhere? ☐ No ☐ Yes, Name of the Provider: ______

GENERAL HEALTH AND MENTAL HEALTH AND SOCIAL INFORMATION

3. Do you currently have a primary physician? ☐ No ☐ Yes,

If yes who is your primary carephysician : ______

When was your last physical? ______

4. Are you currently taking any prescription medication? ☐ No ☐ Yes,

If yes, Please list: ______

  1. How would you rate your current physical health? On a scale of 1-10 (1=poor, 10=excellent) ______

Please list any specific health problems you are currently experiencing:______

  1. How would you rate your current sleeping habits? On a scale of 1-10 (1=poor, 10=excellent) ______

Please list any specific sleep problems you are currently experiencing:

______

  1. How would you rate your current nutrition habits? On a scale of 1-10 (1=poor, 10=excellent) ______

Please list any difficulties you experience in your appetite or eating patterns: ______

  1. How many times per week do you generally exercise? ______

What type of exercise do you participate in: ______

FAMILY AND RELATIONSHIPS

  1. What is your current marital status?

☐ Single (never married) ☐ Married ☐ Domestic Partnership ☐ Separated ☐ Divorced ☐ Widowed

If married or in a partnership, how long have you been in this relationship? ______

On a scale of 1-10, How would you rate your current relationship? (1=poor, 10=excellent) ______

  1. Do you have any children? ☐ Yes ☐ No

If yes, Please list any children including their age and primary place of residence

______

______

______

EMPLOYMENT INFORMATION

  1. Are you currently working? ☐ Yes ☐ No

If yes, what is your current position? ______

  1. How many hours do you typical work each week? ______

If yes, are you happy with your current position? ☐ Yes ☐ No

  1. Please list any work-related stressors, if any ______

MENTAL HEALTH INFORMATION

  1. Have you ever experienced any of the following?

NO / YES
Depressed mood
Rapid speech
Anxiety
Panic attacks
Phobias
Sleep disturbances
Hallucinations
Unexplained loss of time
Unexplained loss of memory
Disordered eating patterns
Repetitive thoughts
Repetitive behaviours
Thoughts of self-harm
Thoughts of suicide
Alcohol abuse
Other drug abuse
Problem gambling
Other addictions
  1. Are you currently experiencing feelings of overwhelming sadness, grief or depression? ☐ Yes ☐ No

If yes, for approximately how long? ______

  1. Are you currently experiencing feelings of anxiety, panic attacks or have any phobias? ☐ Yes ☐ No

If yes, for approximately how long? ______

  1. Have you ever experienced thoughts of self-harm or suicide? ☐ Yes ☐ No

If yes, please describe? ______

  1. Are you currently experiencing any thoughts of self-harm or suicide? ☐ Yes ☐ No

If yes, please describe? ______

  1. Have you experienced any significant life changes or stressful events recently? ☐ Yes ☐ No

If yes, please describe? ______

FAMILY HISTORY

  1. Has anyone in your family (immediate family members or relatives) experienced difficulties with any of the following?

NO / YES / FAMILY MEMBER
Depression
Bipolar disorder
Anxiety disorder
Panic attacks
Schizophrenia
Alcohol abuse
Other drug abuse
Problem gambling
Eating disorders
Developmental disabilities
History of trauma
History of self-harm
History of suicide
Chronic illness

OTHER INFORMATION

What would you consider your strengths?

What do you like most about yourself?

What would you consider your struggles?

What are your current goals for therapy?

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