Please note: Information transmitted via internet may not be secure and by participating, you hereby acknowledge, and understand, and agree to the inherent risks and limitations to confidentiality associated with internet use and telepsychology (e.g., risk of public discovery, internet history discovered by others, possibility of hackers, etc). If you are not comfortable submitting this document online, please print off this page and submit a hard copy to your counsellor during your initial meeting.

First Name & Initial

Last Name

Gender
—Please choose an option—MaleFemaleOtherPrefer Not To Say

Address

City, Province/State

Postal Code/Zip Code

Date of Birth
—Please choose an option—JanFebMarAprMayJunJulAugSepOctNovDec—Please choose an option—01020304050607080910111213141516171819202122232425262728293031—Please choose an option—2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919

Best EMAIL address to reach you at:

Phone Number incl. Area Code

Can we leave a message at this number?
—Please choose an option—YesNo

Secondary Phone Number

Can we leave a message at this number?
—Please choose an option—YesNoN/A

Emergency Contact Name

Emergency Contact #

Marital Status
—Please choose an option—SingleEngagedCommon-LawPartnersMarriedDivorcedSeparatedWidowed

Spouse/Partner First Name & Initial

Spouse/Partner Last Name

Spouse/Partner Date of Birth
—Please choose an option—JanFebMarAprMayJunJulAugSepOctNovDec—Please choose an option—01020304050607080910111213141516171819202122232425262728293031—Please choose an option—2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919

Children including Name/Age/Relationship (ie. son, daughter, stepdaughter etc.) and Name/Date of Birth/Relationship

Which therapist are you scheduled to meet with?
—Please choose an option—Jennifer Dawn Watts, MACathy McCurdy, MA RSWAziza Giga-Hirji MSW, RSWKaylee Garside, MASteven Ngu, MCKatherine Jarrell, MSW RSWHeather Nolin, MCBeverly Reed, MACPCarrie-Lee Gibson, MACPAnya Stang, MCShannon Baustad, MCCeleste Rodrigues-Forbes MSW, RSWDaria Nechaieva, MAJacqueline Van Starkenburg, MACPNeelma Singh, MACP

When are you available for counselling sessions
Daytime M-FEveningsSaturday

Comments on Availability

Counselling History (include approx. year, # of sessions and what treatment was sought for)

Briefly describe your previous counselling experience(s): positive/negative, what you appreciated/disliked etc.

What do you want to talk about in counselling? State your main concerns.

Do you have any particular spiritual beliefs?

Would you like your spiritual beliefs to be a part of treatment? There is no right or wrong answer to this question, it is what best suits you and what you’re seeking currently

Will anyone else be attending counselling with you?

Are you currently on medication?
—Please choose an option—YesNo

Please list current medications you are taking

Is there a concern about alcohol use, drug abuse or overuse of prescription/non-prescription drugs?
SelfSomeone elseNeither
Please explain:

How concerned are you about violence? 0 being none and 10 being the most concerned.
SelfSomeone elseNeither
Please explain:

Is there any concern about suicide?
SelfSomeone elseNeither
Please explain:

Anything else you would like your counsellor to know before you start counselling?

If Other, please describe:

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