Intake Form Name* First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code OccupationEmail* Home PhoneMay we leave a message? Yes No Cell Phone/OtherMay we leave a message? Yes No Birth Date* mm dd yyyy AgeGenderMaleFemaleOtherPrefer not to sayMarital Status Married Never Married Domestic Partnership Separated Divorced Widowed Please list any children/ageReferred by (if any)Health and Personal InformationHave you previously received mental health services?(psychotherapy, psychiatric services etc.) Yes No Date & ReasonHave you ever been prescribed psychiatric medication? Yes No Please provide list & datesIs there a history of mental health issues in your family? Yes No Please ExplainDo you take any Presciption medication? Yes No SpecifyDescription on Present ProblemWhy did you decide to seek counselling*What do you want to work on while in counselling?How long has this been a significant problem for you? Please be specific*How would you estimate the severity of the problem at this time?*MildModerateSeriousSevereSignature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Call or Text 204-721-0875 Email soscounselling20@gmail.com
