Name
*
First Name
Last Name
Sex/Gender
*
Age
*
Date of Birth
*
MM
DD
YYYY
Phone Number
*
(###)
###
####
Email Address
*
Home Address
*
Emergency Contact Person and Phone Number
*
Preferred Days/Times for Appointments
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Any Significant health Problems/Concerns
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Medications
*
Date of Last Physical Exam
*
What Brings you in Today?
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What Would You Like to be Different Because of Our Sessions Together?
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When did the Problem Start?
*
When is the Problem/Situation Better?
*
When it is Better, What Have you done to Make the Problem or Situation Better?
*
How Did you Learn About this Counselling Practice?
*
If You Were Referred by a Health Care Provider, Medical Centre, or Referral Services, Please Identify the Source so I can Thank Them. Your Name Will be Kept Confidential. Name of Person or Referring Organization
*
Phone Number and Address of Referral if Applicable
*
Orientation
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Therapy
*
Appointments
*
Contacting your Counsellor
*
Record Keeping
*
Counselling with Family Members
*
Therapist's Supervision, Case Management, and Information Sharing
*
Release of Information with Consent
*
Release of Information without Consent
*
Your Concerns and Rights
*
You are invited to share and discuss any of your concerns regarding counselling directly with your counsellor. It is your right to be informed.
Client Signature
*
First Name
Last Name
Date
*
MM
DD
YYYY