Outtake Form

Your wellbeing is important to us. This outtake form allows us to learn more about our effectiveness and how we can serve you better. If we can assist you in any way in the future, please feel free to contact us again.

All information you provide is confidential.

Date:

Name:

Last

First

DOB: Age:

Last

First

DOB: Age:

Last

First

DOB: Age:

If your contact information has changed since you completed your intake, please indicate your new information below

New Contact Information:

Counsellor

RCC#

General Health and Mental Health Information

1. How would you rate your current physical health?

PoorUnsatisfactorySatisfactoryGoodVery good

Please list any specific health problems you are currently experiencing

2. How would you rate your current sleeping habits?

PoorUnsatisfactorySatisfactoryGoodVery good

Please list any specific health problems you are currently experiencing

3. How many times per week do you generally exercise?

4. Please list any positive changes you have experienced with your appetite or eating patterns since you started counselling.

5. Do you currently experience overwhelming sadness, grief or depression?

NeverRarelySometimesOftenAlways

6. Do you currently experience anxiety, panic attacks or have any phobias?

NeverRarelySometimesOftenAlways

7. Do you currently experience any chronic pain?

NeverRarelySometimesOftenAlways

8. Are you currently taking any prescription (including psychiatric) medication? NoYes

please list?

9. How often do you consume alcohol?

DailyWeeklyMonthlyInfrequentlyNever

a. On average, how much alcohol do you consume when you drink?

1-5 drinks5-10 drinksmore than 10 drinks

10. How often do you engage recreational drug use?

DailyWeeklyMonthlyInfrequentlyNever

11. Are you currently in a relationship (including marriage and common law)? NoYes

a. Since coming to Cares Counselling, the relationships in my life have improved.

Strongly DisagreeDisagreeNeutralAgreeStrongly Agree

Comments:

12. Please list any significant life changes or stressful events that you have experienced since starting counselling.

Additional Infomation

1. Are you currently employed? NoYes

If yes, what is your current employment situation?

2. Do you consider yourself to be spiritual or religious? NoYes

If yes, has your spirituality been impacted by your treatment?

3. What is your overall level of satisfaction with Cares Counselling?

Comments:

4. My counsellor understood and respected me.

Comments:

5. We worked on or talked about what was important to me.

Comments:

6. The therapist’s approach was a good fit for me.

Comments:

7. I am working towards or have met my therapy goals.

Comments:

8. Is there anything else you would like us to know about your experience with Cares Counselling?

Outtake Form

Name:

If your contact information has changed since you completed your intake, please indicate your new information below

New Contact Information:

Counsellor RCC#

Counsellor

RCC#

General Health and Mental Health Information

Additional Infomation

Thank you for your assistance in helping to ensure Cares Counselling continues to provide quality care within our community.

Counsellor

RCC#