Intake Form | Refuge Counselling

Client First Name(Required)

Client Last Name(Required)

Name of Parent or Legal Guardian

If client is under the age of 16

Client Date of Birth(Required)

Email of Client or Parent/Legal Guardian(Required)

If needed, can an email be sent to this address?(Required)

Yes

No

Phone Number(Required)

If needed, can a voicemail be left at this number?(Required)

Yes

No

Preferred Method of Communication

Email

Phone

Marital Status

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Who can we contact in case of an emergency?

First and Last Name

Emergency Telephone Number

Relationship with emergency contact person

How is your physical health at the present time?

Has alcohol abuse been an issue for you or anyone in your family?

Yes

No

If yes, please explain

In the last year, have you had any major life changes?

(E.g., new job, relationship change, moving, illness, death in the family, etc.)

Are you currently receiving any psychological services, professional counseling, psychiatric services, or any other mental health services?

Yes

No

Are you currently taking any psychiatric prescription medication?

Yes

No

Have you been prescribed psychiatric prescription medication in the past?

Yes

No

Please note any family history of mental health diagnoses

(E.g., depression, anxiety, panic attacks, bipolar disorder)

Do you attend church?

Yes

No

If yes, which church?

Briefly explain your reason(s) for coming to counselling at this time.

What have you been trying to do to help face these struggles?

Who knows about this? Who else may be helping you?(Required)

What lifelong patterns, themes, or habits are you aware of in yourself?(Required)

What experiences from your past may have most affected you?(Required)

Please review the Informed Consent for Counselling Services document.

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