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Equal Counselling & Coaching
INTAKE AND CONSENT FORM
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Monique Verhoef, Registered Therapeutic Counsellor (#2201)
First and Last Name
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Address and postal code
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Email
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Phone
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Date of Birth
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Emergency Contact
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Do you have any thoughts of self-harm?
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Do you have trouble sleeping?
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Are you on any medication that support your mental well-being?
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