Intake Form

Please complete this intake form prior to your first appointment. This allows your counsellor to understand your concerns and obtain essential information about your background. It is considered to be confidential information between you and your counsellor and will not be used for any other purposes. We will not contact any person listed without your prior written consent. Questions marked with an asterisk (*) require a response.

*Full Names

Vocation / Occupation

Addressed to Paddy Carole Either

Personal Contact Information

*Home Address

*City

*Postal Code

*Home Phone

Work Phone

*Cell Phone

*Email

*What number should we use to contact you?

What is the best time to contact you?

Names and Ages of Self and Spouse or Partner

Children or Others

Parents or Others

Third Party Contact Information

Your Medical Doctor

His/her phone number

Please list any other psychiatrists / psychologists / counsellors that you have seen recently or in the past

What is your church / synagogue / other faith community? Who is the minister or leader?

Who referred you to us? (phone and/or email)

Your Present Concerns for Counselling

Please describe your present concerns or reasons to request counselling or other assessment.

Personal / spiritual / emotional concerns?

Relational / premarital / marital concerns?

Family / extended family / parenting concerns?

Vocational / direction / academic concerns?

Summary

The specific "helps" I want my counsellor to provide for me are

What I see I will need to do to obtain benefits is (be specific)

My specific concerns in seeking help at this time include ...

*Spam Check4+3=? 

I've read and understand the Confidentiality Agreement (PDF)