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Intake Form
Please fill in the information below prior to your first session. Information provided on this form is protected as confidential information.
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Email
*
Your email
Name:
*
First Name, Last Name
Your answer
D.O.B.:
*
MM
/
DD
/
YYYY
Client Code
*
Please ensure that you enter the Code as follows:
First
2
letters of your
FIRST NAME
First
2
letters of your
LAST NAME
Last
2
digits of your
BIRTH YEAR
Example: SHRU75
Your answer
Gender:
*
Female
Male
Prefer not to say
Other:
Street Address:
*
Your answer
City:
*
Your answer
Postal Code:
*
Your answer
Telephone (Primary):
*
e.g. (519) 111-1111 **Please indicate if it is okay to leave a message**
Your answer
Emergency Contact:
*
Please state family, friends, etc.
Your answer
Email Address:
*
**Please indicate if it is okay to send and initial email**
Your answer
Marital Status:
*
Married/Common Law
Single (Never Married)
Separated or Divorced
Widow/Widower
Other:
Referral Source:
How did you learn of this service? Please check all that apply
Self-Help Group (AA, NA, CA, GA, SA, SAA, SMART Recovery etc.)
Mental Health Professional/Counsellor
Web Browser Search Engine
Health Care Provider (Doctor, Nurse Practitioner)
Friend/Family
Psychology Today
Other:
Treatment Mandated By:
*
None - Personal Decision
Condition of Family
Condition of Employer
Condition of School
Other:
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