Skype counselling

New Client Intake Form

Share a little bit about yourself

Helpful Information

Please provide the following information and submit it prior to your first appointment. If you have concerns about providing any of the following information, please feel free to leave it out.

Full Name

Skype Name

Email

Phone Number

Current Occupation

Full time/Part time

Full timePart time

Relationship Status

SingleMarriedPartneredSeparatedDivorcedWidowed

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?

YesNo

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?

YesNo

If yes, please give the dates and the nature of the concern at the time

How would you rate your current sleeping habits?

PoorUnsatisfactorySatisfactoryGoodVery good

Please list any specific sleep problems you are currently experiencing.

Are you currently experiencing overwhelming sadness, grief, or depression?

YesNo

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 professionalFriend/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?