Individual Intake Form Δ
Province
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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?
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?
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.)
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?
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