Full Name
Skype Name
Email
Phone Number
Current Occupation
Full time/Part time
Full time Part time
Relationship Status
Single Married Partnered Separated Divorced Widowed
Partner/Spouse’s Name
Age
Years in Relationship
Children (Gender, Age)
Please list any significant current or past medical problems
Have you ever seen a psychologist, psychiatrist, or a counsellor?
Yes No
If yes, please provide the name of the professional, the dates you saw them (e.g., Sept 2000 – April 2001), and the reason for treatment.
Have you ever been hospitalized for a mental health concern?
Yes No
If yes, please give the dates and the nature of the concern at the time
How would you rate your current sleeping habits?
Poor Unsatisfactory Satisfactory Good Very good
Please list any specific sleep problems you are currently experiencing.
Are you currently experiencing overwhelming sadness, grief, or depression?
Yes No
If yes, for approximately how long?
What is the nature of the concern that you wish to address in therapy? For example, feeling overwhelmed, stress, mood problems, feeling anxious, difficulty adjusting to a health issue, etc.
In order for therapy to be most effective, it helps to have a specific goal. What do you hope to achieve in therapy? Feel free to leave this blank if you are uncertain and prefer to discuss this at your initial appointment
How did you hear about us?
Family doctor . Other health professional Friend/family member . Search engine (e.g., Google) . Other
Is there anything else you think would be helpful for me to know about you before we begin working together?
