Intake Form

Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.

Please fill out this form and submit back to us

Name
(Last) (First) (Middle Initial)

Name of parent/guardian (if under 18 years)
(Last) (First) (Middle Initial)

Birth Date
(dd/mm/yyyy)

Age

Gender
MaleFemale

Marital Status
Never MarriedDomestic PartnershipMarriedSeparatedDivorcedWidowed

Please list any children/age

Address

Home Phone

May we leave a message?
YesNo

Cell/Other Phone

E-mail
*Please note: Email correspondence is not considered to be a confidential medium of communication.

Referred by (if any)

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
NoYes

If Yes, previous therapist/practitioner

Are you currently taking any prescription medication?
YesNo

Please list

Have you ever been prescribed psychiatric medication?
YesNo

Please list and provide dates

Please tick one (or more) services would you wish to have
Counseling
IndividualCoupleFamilyRelationship
Life Coaching
IndividualKidsPre teen / TeenMarriage / CoupleSpecial Needs Parents / Children

Notes