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Client Intake Form
Full name
*
Date of Birth
*
Year
Month
Day
Gender
Pronouns
Contact Information
Address
*
Phone
*
Email
*
Preferred Method of Contact
Phone
Email
Text
Emergency Contact
Name
*
Relationship
*
Phone
*
Primary Reason for Seeking Services
Please briefly describe what brings you here and what you would like support with:
*
Relevant Background Information
Share only what you feel comfortable providing.
Previous therapy or counselling experience:
Current stressors or challenges:
Strengths or supports in your life:
Health Information
Primary Care Provider
Medications
Any current medical or mental-health diagnosis
Do you have any accessibility needs or accommodations? If yes, please describe your needs
Insurance Information (if applicable)
Do you have private insurance or are covered by a third party payer? If so would you please provide the name of the company:
Policy Number
Does your plan require a referral?
Yes
No
Scheduling Preferences
Preferred Days
Preferred Times
Session Format
In-person
Virtual
No preference
Submit
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