Mental Health Intake Form

Street Address *

City *

Postal Code *

Health Card Number *

Phone Number

Physical Health

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

6-7

Less than 6

More than 8

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

How do you cope with it?

Current Symptoms

Relationships

Relationship Status *

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

Who do you currently live with? *

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

family member, friend, other

Mental Health

What was their relation to you?

Present Situation

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

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? *

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?