Name
First Name
Last Name
Sex/Gender
*
Age
*
Date of Birth
*
MM
DD
YYYY
Partner's Name
First Name
Last Name
Partner's Sex/Gender
*
Partner's Age
*
Partner's Date of Birth
*
MM
DD
YYYY
Child's Name
*
First Name
Last Name
Child's Sex/Gender
*
Child's Age
*
Child's Date of Birth
*
MM
DD
YYYY
Phone Number
*
(###)
###
####
Email Address
*
Home Address
*
Emergency Contact Person and Phone Number
*
Preferred Days/Times for Appointments
*
Any Significan health Problems/Concerns
*
Medications
*
Date of Last Physical Exam
*
What Brings you in Today?
*
What Would You Like to be Different Because of Our Sessions Together?
*
When did the Problem Start?
*
When is the Problem/Situation Better?
*
When it is Better, What Have you done to Make the Problem or Situation Better?
*
How Did you Learn About this Counselling Practice?
*
If You Were Referred by a Health Care Provider, Medical Centre, or Referral Services, Please Identify the Source so I can Thank Them. Your Name Will be Kept Confidential. Name of Person or Referring Organization
*
Phone Number and Address of Referral if Applicable
*
Orientation
*
Therapy
*
Appointments
*
Contacting your Counsellor
*
Record Keeping
*
Counselling with Family Members
*
Therapist's Supervision, Case Management, and Information Sharing
*
Release of Information with Consent
*
Release of Information without Consent
*
Your Concerns and Rights
*
You are invited to share and discuss any of your concerns regarding counselling directly with your counsellor. It is your right to be informed.
Client Signature
First Name
Last Name
Partner's Signature
First Name
Last Name
Date
*
MM
DD
YYYY