Intake form

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. Please read the Confidentiality and Professional Care form located here before starting this intake form. Questions marked with an asterisk (*) require a response.

Full Names *

Vocation / Occupation

Addressed to

Paddy CaroleEither

(scroll to choose)

PERSONAL CONTACT INFORMATION

Home Address *

City *

Postal Code *

Home Phone *

Work Phone

Cell Phone *

Email *

What phone 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

I have read and understand the above Confidentiality Agreement *

yesno

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