Counselling Intake Form Template – Canada

The Counselling Intake Form Template – Canada is offered in multiple formats, including PDF, Word, and Google Docs. These formats are designed to be both customizable and print-ready, ensuring they cater to your specific requirements.

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Sample

Counselling Intake Form Template – Canada

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1. Client Information



2. Emergency Contact Information


3. Reason for Counseling

4. Previous Counseling Experience

5. Medical History

6. Current Medications

7. Goals for Counseling

8. Consent to Treatment

9. Signature and Date


PDF

WORD

Examples

Counselling Intake Form Template – Canada (1)
Client Information:
Name: [Client’s Name]
Date of Birth: [Client’s DOB]
Address: [Client’s Address]
Phone Number: [Client’s Phone]
Email: [Client’s Email]
Emergency Contact:
Name: [Emergency Contact Name]
Relationship: [Relationship]
Phone Number: [Emergency Contact Phone]
Referral Information:
How did you hear about our services? [Referral Source]
Referred by: [Referred By]
Presenting Concerns:
Please describe the main issues you would like to address during your counselling sessions: [Concerns]
Medical History:
Do you have any medical conditions? [Yes/No]
If yes, please specify: [Conditions]
Psychological History:
Have you received counselling or therapy before? [Yes/No]
If yes, please provide details: [Previous Therapy Details]
Goals for Counselling:
What do you hope to achieve through counselling? [Goals]
Consent:
I give consent for the information provided on this form to be used for the purpose of my counselling sessions.
Client Signature: _____________________ Date: [Date]
Counselling Intake Form Template – Canada (2)
Client Details:
Full Name: [Client’s Full Name]
Date: [Date]
Address: [Client’s Address]
Contact Number: [Client’s Contact Number]
Emergency Information:
Name: [Emergency Contact’s Name]
Contact Number: [Emergency Contact’s Number]
Reason for Seeking Counselling:
Briefly describe why you are seeking counselling: [Reason]
History of Presenting Issues:
Please provide a brief history of the issues you are currently facing: [History]
Current Medications:
Are you currently taking any medication? [Yes/No]
If yes, please list: [Medications]
Previous Counselling Experience:
Have you previously experienced counselling or therapy? [Yes/No]
Please provide details if applicable: [Details]
Session Goals:
What are your objectives for this counselling experience? [Session Goals]
Agreement and Consent:
I understand and agree to the terms outlined in this form.
Client Signature: _____________________ Date: [Date]

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Counselling Intake Form Template - Canada