Home
Find your counsellor
Saskatoon
Martensville
Regina
Canwood / Prince Albert
Swift Current
Warman
Humboldt
Nipawin
Moose Jaw
Estevan
Biggar
Rates
Intake Forms
Child & Teen Intake forms
Adult Intake form
Digital Consent Form
Join our team
Contact Julie Cassidy
Adult intake form
CLIENT INFORMATION
to be completed by all
new
and any
former
clients who have not been seen for 12 months or more.
*
Indicates required field
Primary Client(s) Full Name
*
First
Last
Street Address
*
City/Town
*
Postal Code
*
Cell Phone/Main Phone
*
Home Phone
*
Work Phone
*
Other Phone
*
Preferred method of contact
*
Call
Text
Age
*
Date of Birth (MM/DD/YYYY)
*
Gender
*
Other/Please select
Female
Male
Occupation
*
Years of service
*
Relationship status
*
Single
Committed Relationship
Common Law
Married
Separated
Divorced
Widowed
Emergency contact
Emergency Contact's Name
*
First
Last
Emergency Contact's Phone Number
*
Family Information:
(Who you are residing with at this time. Ex. Mother, Father, Spouse, or Children).
Mother's Name
*
First
Last
Mother's Age
*
Spouse's Name
*
First
Last
Spouse's Age
*
Father's Name
*
First
Last
Father's Age
*
Children's Name(s)
*
First
Last
Children's Name(s)
*
Significant others
*
Such as brothers, sisters, grandparents, step-relatives, half-relatives, please specify relationship.
Please answer only the questions that apply, or that you are comfortable answering.
The facts of this form will be held in the strictest confidence. If you are filling this form out on behalf of someone else, answers should be from the client’s perspective.
Personal History
*
Briefly describe what brought you here today. Some examples might be: anger management, anxiety, depression, eating disorder, fear/phobias, loss or grief, self-esteem, suicide, self-injury, bullying, abuse, addictions, separation/divorce, parenting.
Approximately, how long have you had this concern
*
What are your goals for counselling?
*
Are there special, unusual, or traumatic circumstances that have affected your life?
*
What strengths and qualities do you admire about yourself?
*
Has there been a history of child abuse?
*
Yes
No
If yes, which type(s)?
*
Sexual
Physical
Verbal
Medical/Physical Health
Please list any current health concerns:
*
Medication(s) and Reason for Medication(s)?
*
Physician’s Name:
*
First
Last
Family history of medical problems
*
Chemical Use History
Are you currently using any alcohol or drugs?
*
No
Yes
If yes, what are you using and how long have you been using?
*
Describe any changes in your use patterns:
*
Describe when and where you typically use substances:
*
Describe how your use has affected your family or friends:
*
include their perceptions of your use.
Reason(s) for substance use:
*
Addiction
Builds Confidence
Escape
Self-medication
Social activity
Taste
Check any boxes that you feel apply.
If a reason is not listed, please list it below
*
Who or what has helped you in stopping or limiting your use?
*
How do you believe your substance use affects your life?
*
Does/Has someone in your family present/past have/had a problem with drugs or alcohol?
*
No
Yes
If yes, please specify who and why someone has/had a problem with drugs/alcohol
*
Have drugs or alcohol created a problem for your job/personal life?
*
No
Yes
if yes, specify how have drugs/alcohol created a problem for your job/personal life?
*
Counselling/Prior Treatment History
Are you seeing another counsellor at this time?
*
No
Yes
Current or Prior Psychiatric treatment?
*
No
Yes
If yes, please describe the psychiatric treatment
*
Do you feel suicidal at this time?
*
No
Yes
if you are suicidal at this time please elaborate
*
Hospitalizations?
*
No
Yes
if yes, please describe the hospitalization
*
Have you had counselling prior to today?
*
No
Yes
if yes, please describe the counselling
*
Suicidal thoughts/attempts?
*
No
Yes
If Yes, please describe the suicidal thoughts/attempts
*
Drug/alcohol treatment?
*
No
Yes
if yes, describe the drug/alcohol treatment
*
Involvements with self-help groups?
*
No
Yes
Such as AA, Al-Anon, NA, etc
If yes, please elaborate on your involvements with any self-help group(s)
*
Any additional information that would assist in understanding your concerns or problems?
*
Finally, Who/what referred you to The Counselling Corner?
*
Relative
Friend
Website
Facebook
Kijiji
Phone book
Other
BY CLICKING "SUBMIT" THE CLIENT AGREES TO SHARE THE INFORMATION ENTERED THROUGHOUT THIS FORM WITH
Julie Cassidy
ALL ANSWERS ARE CONFIDENTIAL AND WILL NOT BE SHARED WITH ANYONE ELSE BESIDES THE THERAPIST.
SIGNATURES WILL BE GATHERED UPON THE INITIAL APPOINTMENT.
Submit
Home
Find your counsellor
Saskatoon
Martensville
Regina
Canwood / Prince Albert
Swift Current
Warman
Humboldt
Nipawin
Moose Jaw
Estevan
Biggar
Rates
Intake Forms
Child & Teen Intake forms
Adult Intake form
Digital Consent Form
Join our team