← Return to forms & documents Psychotherapy Intake Form Name * First Name Last Name What has led you to seek counselling / therapy at this time? * How long have you been having these challenges? How do these difficulties affect you in your day-to-day functioning? How have you been coping with these difficulties until now? Have you received counselling / therapy in the past? If yes, when was this? What would you like to gain from counselling / therapy now? Have you received a medical diagnosis for any physical or mental health concern? If yes, please specify below: Do you experience any issues with your appetite? Are you currently or have you recently experienced any high stress situations? (If yes, please note the reason) Do you have any concerns about being in therapy? If yes, please elaborate: MEDICATIONS Are you currently taking any medication(s)? Prescription Please note the details of your prescription (Name, Dose, Purpose) Over the counter Please note the details (Name, Dose, Purpose) Supplements Please note the details (Name, Dose, Purpose) STRESSORS Are any of the following stressors a constant in your life: Smoking Please note your intake – ex: packs/day Alcohol Please note your intake – ex: quantity per day, type, frequency Coffee / Caffeinated Drinks Please note your intake – ex: cups/day Recreational drugs Please note your intake - ex: quantity per day, substance, frequency AGREEMENT By agreeing, you confirm that: * I confirm that the information I have provided in regards to my current condition and past health history are to the best of my knowledge. I also acknowledge that it is my responsibility to update the clinic in regards to any changes in my health condition. I also authorize the release of my medical condition to my family physician. Agree Disagree Thank you!We’ve received your form, see you at your appointment!
