THE COUNSELLING CORNER
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Contact S. WENDY KRITZER

    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.
    Emergency contact
    Family Information: (Who you are residing with at this time. Ex. Mother, Father, Spouse, or Children).
    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.
    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.
    Medical/Physical Health
    Chemical Use History
    include their perceptions of your use.
    Check any boxes that you feel apply.
    ​Counselling/Prior Treatment History
    Such as AA, Al-Anon, NA, etc

    BY CLICKING "SUBMIT" THE CLIENT AGREES TO SHARE THE INFORMATION ENTERED THROUGHOUT THIS FORM WITH S. WENDY KRITZER. ALL ANSWERS ARE CONFIDENTIAL AND WILL NOT BE SHARED WITH ANYONE ELSE BESIDES THE THERAPIST.

    ​SIGNATURES WILL BE GATHERED UPON THE INITIAL APPOINTMENT.

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THE COUNSELLING CORNER


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  • Home
  • Find your counsellor
    • Saskatoon
    • Martensville
    • Regina
    • Canwood / Prince Albert
    • Swift Current
    • Warman
    • Humboldt
    • Nipawin
    • Biggar
    • North Battleford
  • Rates
  • Intake Forms
    • Child & Teen Intake forms
    • Adult Intake form
    • Digital Consent Form
  • Join our team