cares.info@gmail.com
604-853-8916
604-870-8916

    Client Information

    For couples or families, you may fill out one form if preferred. Use initials to indicate answers.

    Date:
    First Name
    Last Name
    DOB: Age: Gender:
    First Name
    Last Name
    DOB: Age: Gender:
    First Name
    Last Name
    DOB: Age: Gender:

    Address:

    City:

    PC:


     

    Contact Information:

    Home Phone:    May we leave a message?
    Cell/Other Phone:   May we leave a message?
    E-mail:   May we email you?
    *Please note: Email correspondence is not considered to be a confidential medium of communication.
     

    Emergency Contact:

    Name:
    Phone:
    Relationship:

     

    If you are completing this intake on behalf of a minor, please complete this section (under 19):

    Parent/Guardian First Name
    Parent/Guardian Last Name
    DOB: Age: Gender:
    Phone:
    Email:

    Parent/Guardian First Name
    Parent/Guardian Last Name
    DOB: Age: Gender:
    Phone:
    Email:

    Parenting Decision-Making Rights Agreement:


    Initial:
    Initial:
    Initial:
     

    Financial Information:

    Insurance Coverage:   Sponsored By:  
    If no insurance, your counselling rate will be based on household income (see fee schedule):

    Credit Card Information

    Credit card information will only be used for pre-paid online appointments and no show/late cancellations.
    Card Number:
    Expiry:
    CVV:

     

    Availability:

    Please check all times you are available.
    Monday
    Tuesday
    Wednesday
    Thursday
    Friday
     

    Counsellor Preferences:

    Counsellor Preference:
    Counselling Format:
    Specific Therapist Request:
    How did you hear about Cares?

     

    Health & Mental Health

    Have you previously received any type of mental health services?
    ,  previous therapist/practitioner  
    Type of Treatment:

    Have you received a formal mental health diagnosis from a physician?
      Diagnosis:

    Have you been prescribed medication for this mental health condition?
      (Please list)  

    Physical Health:
    Current health issues:
    Medications:

    Do you experience chronic pain?
    When did you start experiencing this?

    Sleep Quality:

    Exercise per week:   Type:

    Appetite/eating issues:

    Are you experiencing sadness, grief, or depression?
    When did you start experiencing this?

    Suicidal thoughts/attempts:
    (If you are in immediate need of support please call 310-6789 or go to your nearest hospital.)
     
    Are you experiencing anxiety, panic attacks, or phobias?
    When did you start experiencing this?

    Have you experienced a traumatic brain injury (including concussions)?
    If yes, what year(s) did it occur?

    Please describe if you have experienced traumatic events (Mentally, Emotionally, and/or physically):

    Do you have concerns about violence in your current living situation?

    Alcohol use:
    How many drinks on average do you consume?

    Recreational drug use:
    Type:
    Other:

    Have you been prescribed cannabinoid medication?

     

    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.
    Yes/No
    Family Member(s)
    Alcohol/Substance Abuse
    Anxiety
    Depression
    Domestic Violence
    Eating Disorders
    Obsessive Compulsive Disorder
    Schizophrenia
    Suicide Attempts
    ADHD/ADD
    Other

     

    Additional Information

    Marital Status:


    Are you currently in a relationship?
    If yes, how long have you been together?
    On a scale of 1-10 with 1 being the lowest, how would you rate your relationship?

    Children (Names & Ages):

    Please list any significant life changes or stressful events that you have experienced recently:

    Employment:   Occupation:
    Do you enjoy your work? Stressful aspects:

    Spiritual/Religious:   Describe:

    What are your main goals for counselling?

     

    Information about Informed Consent, Confidentiality & Financial Policy

    Counselling provides an opportunity to explore behaviours, feelings, and relationships. It may bring personal insight and positive change. It may also involve discussing difficult topics and strong emotions.

    Confidentiality: Information is confidential except when:

    • A child is at risk of abuse/neglect
    • You or another person is at imminent risk of harm
    • Disclosure is required by law (e.g., subpoena)

    With your consent, information may be shared in supervision/consultation. Concerns can be addressed with your counsellor or the Executive Director (604-853-8916).

    • Sessions cost Cares $150 but subsidized rates, based on household income, are available.
    • Supported by donations, sponsorships, and client contributions.
    • Payment is due before sessions. Outstanding balances may suspend counselling.
    • Cancellations require 48 hours' notice. Late cancellations or no-shows are charged in full. Two no-shows may suspend counselling.

    *Your counsellor will review our full informed consent, confidentiality, and financial policy at your first session.

     
    Name of Client:
    Name of Client: