Rapids Family Health Team | Improving the health and well-being of our patients

Mental Health Intake Form

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Date *

Year

Month

Day

First Name *

Last Name *

Preferred Name

Preferred Pronoun

Gender

Street Address *

City *

Postal Code *

Health Card Number *

Date of Birth *

Age *

Preferred contact number *

Can a detailed voicemail message be left? *

Yes

No

Email *

Can a detailed email be left? *

Yes

No

Emergency contact

Relationship

Phone Number

Is English your first language

Yes

No

If not, what is your first language?

Family Physician *

Referral Source

Self

Other

Other Referral Source

Physical Health

Do you exercise regularly?

Yes

No

Infrequent

Details

On average, how many hours of sleep are you getting a night?

6-7

Less than 6

More than 8

Do you have any problems with sleep?

Yes

No

Explain

Do you have any difficulty eating or have you noticed changes in your appetite?

Yes

No

Explain

Please list any current physical health problems you are experiencing: (i.e.: Chronic pain)

How do you cope with it?

Relationships

If so, how long have you been in your current relationship?

Is this relationship healthy?

Yes

No

Details

Who do you currently live with? *

Do you have children? *

Yes

No

If yes, how many?

What are their ages?

Do you have custody/access of your children?

Yes

No

Details

Do you have a healthy relationship with each of your children?

Yes

No

Details

Who do you consider to be part of your support system? *

family member, friend, other

Mental Health

Have you been diagnosed with a mental health disorder? *

Yes

No

Unsure

Details

Have you ever been hospitalized for a mental illness?

Yes

No

If so, when?

Are you currently taking any medications for your mental health?

Yes

No

Medications

Is there any history of mental illness in your family?

Yes

No

Unsure

Details

Are you concerned with your alcohol or substance use?

Yes

No

Details

Is anyone close to you concerned with your alcohol or substance use?

Yes

No

If yes, please list

Has anyone close to you died by suicide? *

Yes

No

If yes, how long ago

What was their relation to you?

Are you experiencing thoughts of suicide? *

Yes

No

If so, how recent or often?

Have you engaged in self-harm behaviours?

Yes

No

Details

Have you had thoughts of harming others? *

Yes

No

Details

Has your mental health impacted your ability to participate in activities of daily living?

Yes

No

Details

Present Situation

Are you employed?

Yes

No

What type of work do you do?

Is your job a source of stress?

Yes

No

Details

What is your main source of income *

Employment

OW/ODSP/CPP

Other

Do you have access to Group Insurance benefits or an Employee Assistance Plan that covers counselling/therapy costs? *

Yes

No

Unsure

Have, or are you connected with any other community agencies, resources? *

Yes

No

Please List *

Are you currently engaged in services with other professionals/ programs to support your mental health? *

Yes

No

Please List *

e.g.: psychologist/ psychiatrist / other mental health professional

Counselling objectives

What brings you to counselling at this time? Describe the current problems as you see them *

How long have you been dealing with this? *

Have you experienced any recent significant life changes or stressful events? *

Yes

No

Details

How have you managed to cope with difficult issues in the past?

What do you hope to gain from short term counselling? *

Are you committed to attending individual therapy to work on self-identified goals? *

Yes

No

Unsure

Preparing for the appointment

Is there a preferred day/time that works for you *

between M-F 8-4:00

Do you prefer a counsellor who is *

Male

Female

No Preference

Have you received counseling with Rapids Family Health Team in the past? *

Yes

No

If yes, when?

Have you received therapy/counseling outside of the Family Health Team?

Yes

No

Where/when did you receive these services?

Is there anything else that you feel is important or helpful for a counsellor to know?

Leave this field blank

Read more about Mental Health Intake Form

COVID Testing & Respiratory Clinic

If you are experiencing COVID 19 or Respiratory Symptoms call your Primary Care Provider for a referral. If they are unavailable to see you -

Book your COVID test @ getcorigan.ca or call 519-491-5395 for a Respiratory Assessment.

OPEN @ 1150 Pontiac Dr., Sarnia

Monday & Tuesday 8AM - 4:30 PM

Wednesday & Thursday 11:30AM - 7:30PM

Friday 8AM - NOON

Closed Monday September 5, 2022 for Labour Day

Read more about COVID Testing & Respiratory Clinic

COVID19 Reources - BrainXchange

Click here for a pdf of Heads Up To Healthier Brains

Resources: Alzheimer's Society (click here)

Canada's Physical Activity Guide to Healthy Living (click here)

Read more about MINT Memory Clinic

Access to Care Centre

Rapids Family Health Team Access to Care Centre continues to be open to everyone for episodic medical conditions, ie. urinary tract infections, ear aches, rashes, etc. If you are unwell and can’t get in touch with your primary care provider we are here to help.

To book an appointment with a Nurse Practitoner call 519-491-6188

OPEN Monday thru Thursday 8:00 AM – 4:30 PM

Open Fridays 8:00 AM - NOON

Closed Monday September 5, 2022 for Labour Day

Read more about Access to Care Centre

Access to Care Centre

2019 Holiday Hours

Saturday December 14 9am-2pm

Sunday December 15 Closed

December 16 - December 20 8am -5pm

Saturday December 21 9am-2pm

Sunday December 22 Closed

Monday December 23 8am - 5pm

Tuesday December 24 8am - noon

Wednesday December 25 CLOSED

Thursday December 26 CLOSED

Friday December 27 9am - 2pm

Saturday December 28 9am - 2pm

Sunday December 29 Closed

Monday December 30 9am - 2pm

Tuesday December 31 9am - 2pm

Wednesday January 1 CLOSED

Read more about Access to Care Centre

Healthy Habits Community Teaching Kitchen

Read more about Healthy Habits Community Teaching Kitchen

Teen Cuisine

FREE Cooking Sessions for Teens Ages 13+

Monday June 18th

5:00 - 7:00 PM

Pre-register by calling 519-339-8949

Read more about Teen Cuisine

Register

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Read more about Register

Welcome to Rapids

Main Clinical Site

1150 Pontiac Dr., Sarnia Phone: 519-339-8949

OPEN Monday - Thursday 8:00 AM - 4:30 PM and Fridays 8:00 AM - Noon

Closed Monday September 5, 2022 for Labour Day

Rapids FHT Access to Care Centre for eposidic medical care

By appointment call 519-491-6188

OPEN Monday - Thursday 8AM - 4:30 PM and Fridays 8AM - Noon

Closed Monday September 5, 2022 for Labour Day

Read more about Welcome to Rapids

Search form

Access to Care Centre

Rapids Family Health Team Access to Care Centre continues to be open to everyone for episodic medical conditions, ie. urinary tract infections, ear aches, rashes, etc. If you are unwell and can’t get in touch with your primary care provider we are here to help.

COVID Testing & Respiratory Clinic

OPEN @ 1150 Pontiac Dr., Sarnia

Welcome to Rapids

Main Clinical Site

Mental Health Intake Form

COVID Testing & Respiratory Clinic

OPEN @ 1150 Pontiac Dr., Sarnia

Access to Care Centre

Rapids Family Health Team Access to Care Centre continues to be open to everyone for episodic medical conditions, ie. urinary tract infections, ear aches, rashes, etc. If you are unwell and can’t get in touch with your primary care provider we are here to help.

Access to Care Centre

2019 Holiday Hours

Healthy Habits Community Teaching Kitchen

Teen Cuisine

Register

Welcome to Rapids

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