VANCITY COUNSELLING

Intake Form

Name ______Age _____ Gender______Date of Birth ____/____/____

Street Address ______

City / Province / Postal Code ______

Email Address ______

Home Phone ______Work Phone ______Cell Phone ______

May we leave a message? YES NO 

Name of Parent/Guardian (if under 18 years of age) ______

Home Phone ______Work Phone ______Cell Phone ______

Marital Status: Single  Married  Domestic Partnership  Separated  Divorced  Widowed 

Spouse’s Name ______Date of Birth ____/____/____

Please list any children and their ages ______

Who referred you / how did you hear about us? ______

Have you previous received any type of mental health service (counselling therapy, psychiatric services, etc.)?

YES NO 

If yes, please provide name of previous counsellor/practitioner ______

Do we have permission to contact previous counsellor/practitioner? YES NO 

Are you currently employed? YES NO 

If employed, please list your occupation ______Employer______

Do you consider yourself to be spiritual or religious? YES NO 

If so, please describe your faith or belief ______

Are you currently taking any prescription medication? YES NO 

If yes, please list ______

Have you ever been prescribed any psychiatric medication? YES NO 

If yes, please list ______

Check any problems you are currently experiencing (within the last four weeks):

Appetite gainAppetitelossWeight gainWeight lossFatigue

BlackoutsDizzinessDiarrheaConstipationAnxiety

CoughingSkin soresNosebleedsHeadachesChills

NervousnessNauseaNumbnessTrouble breathing

Can’t get to sleepCan’t stay asleepSleeping too much/too little (circle)

Do you drink coffee? ______Estimate how much in a day ______

Do you smoke tobacco? ______Estimate how many cigarettes in a day ______

Do you drink alcohol? ______How much during a drinking occasion ______

Recreational drugs? ______How often/much ______

Is anyone close to you concerned about your drinking/drug usage? ______

Do you exercise? ______How/what? ______

How often? ______

Are youhavingsuicidalthoughts? Yes No Sometimes Often

Is there a history of any of the following in your family (immediate & extended): Circle/mark all that apply:

depressionbi-polaralcoholismdrugabusesexual abuseschizophrenia

suicideeating disorderphysical abusepsychiatric illnessrape

gamblingADHD/ADDuntimely deathother: ______

Current state of physical health: Excellent Good Fair Poor 

Date of last physical examination: ______

Please list the concerns that have led you to seek counselling:

______

______

Please rate the severity of your present concerns on the following scale:

MILD MODERATE 

SEVERE TOTALLY INCAPACITATING 

What do you hope to gain from counselling?

______

______