Intake Form: Individual Your Name Your Email Date of Birth Gender MaleFemaleOther Your Address Your Phone Number May we leave a message? YesNo Insurance Provider Your Emergency Contact Current Health 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 counseling) 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: hallucinations, self-harm, alcohol use, excessive worrying, etc. What are your goals for therapy? Do you have any other comments, questions or concerns?