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Senior Wellness
Mental Health
Nutrition
Diabetes Education
Lung Health
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Clinics
General Health Information
Mental Health Intake Form
You must have JavaScript enabled to use this form.
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Start
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Date
*
Year
Year
2021
2022
2023
2024
2025
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
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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?
Current Symptoms
Anxiety
Depression
Grief
Low Mood
Loss of interest
Low self-esteem
Panic attacks
Feeling hopeless
Inability to feel joy
Excessive worry
Poor Concentration
Lack of motivation
Decreased appetite
Memory impairment
Excessive energy
Fatigue/loss of energy
Dramatic mood swings
Guilt/blame/regret
Trouble controlling emotions
Irritability/easily angered
Delusions/ Hallucinations
Substance misuse
Easily startled
Engage in risky activities
Racing thoughts
Intrusive thoughts/memories
Feeling detached/numb
Impulsive behaviours
Self harm (Daily)
Self harm (Weekly)
Self harm (Monthly)
Self harm (Other)
Suicidal ideation (Daily)
Suicidal ideation (Weekly)
Suicidal ideation (Monthly)
Suicidal ideation (Other)
Relationships
Relationship Status
*
Single
Relationship
Engaged
Married/Common-Law
Seperated/Divorced
Widowed
Remarried
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?
Would you like to share any cultural background details that would be helpful for the counsellor to know?
Is there anything else that you feel is important or helpful for a counsellor to know?
Leave this field blank