Client Intake Form About YouName First Name Surname I identify my gender as Birthdate MM slash DD slash YYYY AgeCurrent Relationship Status Single Partnered Married Common-Law Other If other then please describe: Occupation Address 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? Yes No Cell PhoneIs it OK to leave a message on your cell phone voicemail? Yes No Is it OK to leave a message via Text? Yes No Work PhoneIs it OK to leave a message on your work phone voicemail? Yes No Email Is it OK to leave a message via email? Yes No Preferences Day Evening Other Please describe "Other" Date of Initial Session MM slash DD slash YYYY Local Emergency Contact First Name Surname Emergency Contact Relationship Emergency 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? Yes No If yes, what type? Considered suicide? Yes No If yes, when? Been diagnosed by a psychologist or psychiatrist with a 'mental illness' or DSM disorder (such as clinical depression, borderline personality disorder, etc.)? Yes No If so, what was the diagnosis and when did it occur?Do you have a serious medical condition? Yes No If so, please list them here:Are you currently taking medication? Yes No If so, please list them here:PartnerName First Name Surname Date of Birth MM slash DD slash YYYY AgeLength of Time in Present Relationship Address 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? Yes No Serious Illness? Yes No Addiction? Yes No If 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* MM slash DD slash YYYY