Intake Form - Maitri Counselling & Coaching

INTAKE FORM for COUNSELLING

Sara Londono-Sulkin, M.A. CHC, 1440 Fleury Street Regina, Saskatchewan, S4N 5B1 306.540.4814

Comprehensive Intake Form

Please provide the following information and answer the questions below. I want you to know that information you provide here is protected as confidential information. Please fill out this form before your first session.

First Name

Middle Name

Last Name

Date of Birth Client

Parent First Name

Middle Name

Last Name

Emergency Contact

Relationship to client

Emergency Contact Phone

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

Best Phone Number

May I leave a Message?

Alternative Phone Number

May I leave a Message?

May I email you?

Referred by (if applicable)

Name of the individual who referred you

Prior mental health services (psychotherapy, psychiatric services)?

Name of the therapist/practitioner:

Are you currently taking any prescription medication?

At the first counselling appointment, please share the type of medication, including the dosage and frequency.

Have you ever been prescribed psychiatric medication?

At the first counselling appointment, please share the type of medication, including the dosage and frequency.

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

Please provide any relevant information concerning your physical health and/or sleep habits here

Do you generally exercise?

What kind of exercise?

How many times per week?

Please list any difficulties you experience with your appetite or eating patterns .

Are you currently experiencing overwhelming sadness, grief or depression

For approximately how long

Are you currently experiencing anxiety, panic attacks or have any phobias?

when did you begin experiencing this?

Are you currently experiencing any chronic pain?

Please describe

How often do you drink alcoholic beverages

How often do you engage in recreational drug use?

Are you currently in a romantic relationship?

For how long?

On a scale of 1-10, how would you rate your relationship?

What significant life changes or stressful events have you experienced recently?

FAMILY MENTAL HEALTH HISTORY

In the section below, identify if there is a family history of any of the following.

If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).

Alcohol/Substance Abuse