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Individual Intake Form

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First Name

Middle Name

Last Name

Email

Phone Number

Province

Birthday (DD-MM-YYYY)

Gender

Pronouns

Emergency Contact

Middle Name

Last Name

Emergency Contact Phone

Is there a specific culture(s) that you identify with? If so, which one(s)? (Please type “No” if there is nothing to list.)

Are there any spiritual considerations that are important to you? If so, which one(s)? (Please type “No” if there is nothing to list.)

Please describe what has brought you to seek therapy at this time?

How are your current issues affecting your daily life, and for how long have you been experiencing them?

On a daily basis, how do you typically feel?

Rate your current emotional intensity on a scale of 1 (Low) to 10 (High).

What current stressors are affecting your mental health?

In the past 30 days, what symptoms have you experienced?

Have you experienced trauma at any time in your life? Please provide details.

Have you ever attended mental health therapy before?

Yes

No

What aspects of therapy did you find helpful or unhelpful?

Have you experienced trauma at any time in your life? Please provide details.

Are you taking any medications for these mental health diagnoses? Please list the medications(Please type “No” if there is nothing to list.)

Are you dealing with any physical health conditions at the moment? Please list the conditions and describe the associated symptoms (Please type “No” if there is nothing to list.)

Checkbox Field

Stress

Anxiety

Depression

Trauma

Grief

Substance Abuse

Eating Disorders

Self-Esteem Issues

Relationship Problems

Work or Academic Stress

Financial Problems

Family Issues

Social Isolation

Do you have a history of self-harm and/or suicidal ideation? Please provide more detail about the nature and frequency of this history (Please type “No” if there is nothing to list.)

Are you currently involved in/ or is there the potential for you to be involved in any legal or court proceedings while you are receiving therapy where your therapist’s notes may be requested? (Please type “No” if there is nothing to list.)

Is there anything that you think I should know about you to help me understand you better?

Physician First Name

Physician Last Name

Physician Contact

Peace Unto You Psychotherapy Services

Guiding Your Path to Inner Peace

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kwasi@peaceuntoyou.ca

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