Name
First Name
Last Name
Parent/Legal Guardian (if under 18)
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
May I leave you a phone message?
Yes
No
Email
May I leave you an email message?
Yes
No
Age
Date of birth
MM
DD
YYYY
Gender/Pronoun
Marital status
Married
Domestic Partner
Widowed
Divorced
Separated
Never Married
Referred by (if applicable)
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Yes
No
If yes, when did you attend and for how long?
Are you currently taking any prescription medication?
Yes
No
If yes, please list any prescriptions you are currently taking?
Have you ever been prescribed psychiatric medication?
Yes
No
If yes, please list the medications and provide dates (as best as you can remember)
How would you rate your current physical health?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
Please list any specific health problems you are currently experiencing
How would you rate your current sleeping habits?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
Please list any specific sleep problems you are currently experiencing
How many times per week do you generally exercise?
Once a week
2-3 times a week
4-7 times a week
Less than the options above
What types of exercise do you participate in?
Please list any difficulties you experience with your appetite or eating problems
Are you currently experiencing overwhelming sadness, grief or depression?
Yes
No
If yes, for approximately how long?
Are you currently experiencing anxiety, panics attacks or have any phobias?
Yes
No
If yes, when did you begin experiencing this?
Are you currently experiencing any chronic pain?
Yes
No
If Yes, please describe your pain
How often do you drink alcohol?
Daily
Weekly
Monthly
Infrequently
Never
How often do you use drugs recreationally?
Daily
Weekly
Monthly
Infrequently
Never
What significant life changes or stressful events have you experienced recently?
Please describe your belief system (spirituality, religion, other)
Please indicate if there is a family history of any of the following mental health challenges
For any mental health challenges identified above, please indicate the family member’s relationship to you (e.g. father, grandmother, uncle, etc.)
What would you like to accomplish out of your time in counselling?
