Intake Form: Couple - Southwest Counselling Services

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Our Address: 704 Mara Street, Unit #207, Point Edward, Ontario

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Intake Form: Couple

Intake Form: Couple

Please complete the form below or download the PDF version of this intake form and return to admin@swcounselling.ca.

Your Address(es)*

Your City/Town*

Your Postal Code*

Insurance Provider(s)*

Your Phone Number*

May we leave a message?*
YesNo

Your Emergency Contact(s)*

Individual 1

Your Name*

Your Email*

Date of Birth*

Gender*

Gender Identity

Preferred Pronouns*

Family Doctor*

Please list any other professionals you are working with (e.g. Psychiatrist)

Please list any other agencies that you are working with (e.g. CMHA)

Please list any medications (relevant to counselling)

Please list any significant health issues (past or present)

Have you ever been admitted to hospital for mental health concerns?*
YesNo

Have you previously participated in counselling or psychotherapy?*
YesNo

Are you currently involved in the criminal or family courts? If so, please explain.*

Do you have a finalized custody and access order?*
YesNoNot Applicable

What did you like or dislike about previous treatment?*

Individual 2

Your Name*

Your Email*

Date of Birth*

Gender*

Gender Identity

Preferred Pronouns*

Family Doctor*

Please list any other professionals you are working with (e.g. Psychiatrist)

Please list any other agencies that you are working with (e.g. CMHA)

Please list any medications (relevant to counselling)

Please list any significant health issues (past or present)

Have you ever been admitted to hospital for mental health concerns?*
YesNo

Have you previously participated in counselling or psychotherapy?*
YesNo

Are you currently involved in the criminal or family courts? If so, please explain.*

Do you have a finalized custody and access order?*
YesNoNot Applicable

What did you like or dislike about previous treatment?*

Current Intake Request

Please describe your reasons for seeking treatment at this time*

What have you tried so far to handle the situation?*

Please describe what you are experiencing?* Examples: separation/divorce, grief/loss, alcohol use, excessive worrying, etc.

What are your goals for therapy?*

Do you have any other comments, questions or concerns?*

Do you consent to receive appointment reminders?*
Yes, by textYes, by emailNo

Are you seeking in-person or virtual support?*

Preferred method of communication:*
EmailPhone

About Us

We are a professional collective of qualified counsellors with a passion for helping individuals and families navigate their way through life’s difficulties and challenges.

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Phone: 519-336-3100
Main Location: 704 Mara Street, Unit #207, Point Edward, Ontario
Outreach Location: 19 Baldwin Street, Tillsonburg, Ontario
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