Client Intake Form About YouName First Name Surname GenderBirthdate Date Format: MM slash DD slash YYYY AgeAddress Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home PhoneIt is OK to leave a message on your Home Phone?YesNoCell PhoneIt is OK to leave a message on your Cell Phone?YesNoTextIt is OK to leave a message via Text?YesNoWork PhoneIt is OK to leave a message on your Work Phone?YesNoEmail It is 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 major depression, borderline personality disorder, etc.)?YesNoIf so, what was the diagnosis and when did it occur?Do you have a serious illness?YesNoIf so, please list them here:Are you currently taking medication?YesNoIf so, please list them here:PartnerName First Name Surname Gender Female Male Date of Birth Date Format: MM slash DD slash YYYY AgeAddress Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home PhoneCell PhoneWork PhoneEmail Status Single Married Common-Law Blended Other If other then please describe:Length of Time in Present RelationshipDoes your partner have a family history of:Mental Health Issues, e.g. depression?YesNoSerious Illness?YesNoChemical Dependency?YesNoIf you answered yes to any of the above, please provide more details:Please let me know how you found out about me Internet Clearmind ACCT Doctor Word of Mouth LinkedIn Psychology Today Other Specifics would be appreciated!