Client Intake form

    Please fill in the form below prior to your first session. Please note, information provided on this form is protected as confidential information.

    * Required

    Personal Information


    YesNo


    YesNo

    Please Note: Email correspondence is not considered to be a confidential medium of communication.

    HeSheThey


    YesNo
    If yes, name of previous therapist/practitioner

    YesNo
    If yes, please list.

    General and Mental Health Information

    How would you rate your current physical health (choose one).

    PoorUnsatisfactorySatisfactoryGoodVery Good

    PoorUnsatisfactorySatisfactoryGoodVery Good

    YesNo

    YesNo

    YesNo

    YesNo


    DailyWeeklyMonthlyInfrequentlyNever

    YesNo

    Family Mental Health History

    In the area below, identify if there is a family history of these items. If yes, please check "yes" and indicate the family member's name or member/s relationship to you in the space provided (grandmother, father, uncle, etc.).

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    Additional Information
    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    Thank you for taking the time to complete this Intake Form.