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.

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PERSONAL CONTACT INFORMATION

THIRD PARTY CONTACT INFORMATION

YOUR PRESENT CONCERNS FOR COUNSELLING

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

SUMMARY