Intake Form | CARES

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

Contact Information:

Home Phone

May we leave a message

Yes No

Cell/Other Phone

May we leave a message

Yes No

E-mail

May we email you

Yes No

*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

Parent/Guardian First Name

Parent/Guardian Last Name

DOB

Age

Gender

Phone

Parenting Decision-Making Rights Agreement:

Parenting Rights

None Sole Shared

I understand it is my responsibility to inform the other parent that I am bringing our child to counselling. I may be required to provide our separation agreement and any relevant court orders. Cares Counselling Society requires both parents' consent for counselling.

Initial

All financial arrangements for counselling sessions must be made directly between the parents prior to the start of counselling. Cares Counselling Society does not facilitate or manage these arrangements.

Initial

I understand as part of my child's counselling guardians may be required to participate in sessions with the therapist.

Initial

Financial Information:

Insurance Coverage

Yes No

Credit Card Information

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

Credit Card

Card number Expiry (MM/YY)

Used only for pre-paid online appointments and no-show/late cancellations.

Availability:

Please check all times you are available.

Counsellor Preferences:

Counsellor Preference

Female Male No Preference

Counselling Format

In-person Virtual No Preference

Specific Therapist Request

How did you hear about Cares

Health & Mental Health

Have you previously received any type of mental health services?

Mental Health Yes

Yes

previous therapist/practitioner

Type of Treatment

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

Diagnosis Yes

Yes

Diagnosis

Have you been prescribed medication for this mental health condition?

M H Med Yes

Yes

(Please list)

Current health issues

Medications

When did you start experiencing this

Exercise per week

Type

Appetite/eating issues

When did you start experiencing this

Suicidal thoughts/attempts

No Yes

(If you are in immediate need of support please call 310-6789 or go to your nearest hospital.)

When did you start experiencing this

Have you experienced a traumatic brain injury (including concussions)

No Yes

If yes, what year(s) did it occur

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

Area Traumatic Events

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

How many drinks on average do you consume

Other

Have you been prescribed cannabinoid medication

No Yes

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.

Alcohol/Substance Abuse

Family Member(s)

Anxiety

Family Member(s)

Depression

Family Member(s)

Domestic Violence

Family Member(s)

Eating Disorders

Family Member(s)

Obsessive Compulsive Disorder

Family Member(s)

Schizophrenia

Family Member(s)

Suicide Attempts

Family Member(s)

ADHD/ADD

Family Member(s)

Other

Family Member(s)

Additional Information

Marital Status:

Are you currently in a relationship

No Yes

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

Child List

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

Area Life Changes

Employment

No Yes

Occupation

Do you enjoy your work? Stressful aspects:

Area Work Stress

Spiritual/Religious

No Yes

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

Client1 Date

Client2 Date

Client1 signature

Client2 signature