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

Email *

Can a detailed email be left? *

Yes

Emergency contact

Relationship

Phone Number

Is English your first language

Yes

If not, what is your first language?

Family Physician *

Referral Source

Self

Other

Other Referral Source

Physical Health

Do you exercise regularly?

Yes

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

Explain

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

Yes

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

Details

Who do you currently live with? *

Do you have children? *

Yes

If yes, how many?

What are their ages?

Do you have custody/access of your children?

Yes

Details

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

Yes

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

Unsure

Details

Have you ever been hospitalized for a mental illness?

Yes

If so, when?

Are you currently taking any medications for your mental health?

Yes

Medications

Is there any history of mental illness in your family?

Yes

Unsure

Details

Are you concerned with your alcohol or substance use?

Yes

Details

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

Yes

If yes, please list

Has anyone close to you died by suicide? *

Yes

If yes, how long ago

What was their relation to you?

Are you experiencing thoughts of suicide? *

Yes

If so, how recent or often?

Have you engaged in self-harm behaviours?

Yes

Details

Have you had thoughts of harming others? *

Yes

Details

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

Yes

Details

Present Situation

Are you employed?

Yes

What type of work do you do?

Is your job a source of stress?

Yes

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

Unsure

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

Yes

Please List *

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

Yes

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

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

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

If yes, when?

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

Yes

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

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Mental Health Intake Form