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Intake Form - Sike & Spirit Counseling
All sessions are held virtually. Once your form is received, you'll be contacted and a virtual video link will be provided to you for the first session.
* Indicates required question
First name
*
Your answer
Last Name
*
Your answer
Type of Therapy
*
Individual Therapy ($110/50 min) - or $130 Canadian
Couples, Family, Conjoined Therapy (2+ people in session) ($160/50 min) - $220 Canadian
If couples/ family -- please list partner's name/ family member's names here... if individual please write n/a
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Sex
*
Male
Female
Other
Occupation
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Your answer
Marital Status
*
Choose
Single
Married
Engaged
Divorced
Common-law
Widowed
Spiritual/Religious Orientation:
Do you identify as...
*
Christian
Muslim
Jewish
Buddhist
Hindu
Athiest
Agnostic
Nothing in particular
Other
Prefer not to answer
How many children/dependents?
*
Your answer
Referred by:
*
Psychology Today
Open Path
Christian Counselor Directory
A general Google Search
Word of Mouth (Someone I know)
Other:
If referred by someone you know (a person), please write their name, or if you chose "other" please clarify here (otherwise please write N/A)
*
Your answer
Email:
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Your answer
Address (including zip/postal code, city, and country)
*
Your answer
Phone Number
*
Your answer
OK to send text messages to this number?
*
Yes
No
Required
OK to leave a voicemail at this phone number?
*
Yes
No
Required
Note: the above information will be used solely by Sik & Spirit: Violin Narooz-Gad, LPC-A, MA, CCC, BCCC and the collection purpose is to aid in the helping relationship process.
*
Acknowledged
Required
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