Client Intake Form About YouName First Name Surname I identify my gender asBirthdate Date Format: MM slash DD slash YYYY AgeCurrent Relationship Status Single Partnered Married Common-Law Other If other then please describe:OccupationAddress Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home PhoneIs it OK to leave a message on your home phone?YesNoCell PhoneIs it OK to leave a message on your cell phone voicemail?YesNoIs it OK to leave a message via Text?YesNoWork PhoneIs it OK to leave a message on your work phone voicemail?YesNoEmail Is it OK to leave a message via email?YesNoPreferences Day Evening Other Please describe "Other"Date of Initial Session Date Format: MM slash DD slash YYYY Local Emergency Contact First Name Surname Emergency Contact RelationshipEmergency Contact PhoneFamily Doctor First Name Surname Family Doctor PhoneFamily Doctor Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Please share the short and long term goals you would like to achieve in therapy.Short term goalsLong term goalsHave you ever had counselling in the past? What did and didn't work?Have you ever:Struggled with an addiction?YesNoIf yes, what type?Considered suicide?YesNoIf yes, when?Been diagnosed by a psychologist or psychiatrist with a 'mental illness' or DSM disorder (such as clinical depression, borderline personality disorder, etc.)?YesNoIf so, what was the diagnosis and when did it occur?Do you have a serious medical condition?YesNoIf so, please list them here:Are you currently taking medication?YesNoIf so, please list them here:PartnerName First Name Surname Date of Birth Date Format: MM slash DD slash YYYY AgeLength of Time in Present RelationshipAddress Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home PhoneCell PhoneWork PhoneEmail Does your partner have a history of:Mental Health Issues, e.g. depression?YesNoSerious Illness?YesNoAddiction?YesNoIf you answered yes to any of the above, please provide more details:Please let me know how you found out about me: Internet Psychology Today Association of Cooperative Counselling Therapists of Canada Doctor Word of Mouth LinkedIn Clearmind International Other Specifics would be appreciated! Thank you!I certify that the information provided in this document is true and correct to the best of my knowledge, and that signing my name or initials in the signature box below acts as my legal signature.*Date* Date Format: MM slash DD slash YYYY