The Intake Form Template – Canada is offered in multiple formats, including PDF, Word, and Google Docs. These formats are easily editable and printable, ensuring they cater to your specific requirements effortlessly.
Intake Form Template – Canada Editable – PrintableSample
1. Client Information 2. Purpose of the Intake 3. Services Required 4. Relevant Background Information 5. Emergency Contact Information 6. Consent for Information Collection 7. Additional Notes or Concerns 8. Signature and Declaration
PDF
WORD
Examples
[Client’s Full Name]
[Client’s Date of Birth]
[Client’s Address]
[Client’s Phone Number]
[Client’s Email Address]
[Emergency Contact Name]
[Emergency Contact Phone Number]
[Relationship to Emergency Contact]
Please specify the services you are interested in:
[Service Type]
Please provide details of any existing medical conditions or disabilities:
[Medical History Details]
Please list any known allergies, including medications, food, or environmental allergens:
[Allergy Information]
I hereby consent to the collection and use of my personal information for the purpose of [specific services] in accordance with applicable privacy laws.
[Client’s Signature]
[Date]
[Full Name]
[Date of Birth]
[Residential Address]
[Contact Number]
[Email Address]
Please describe any ongoing health concerns or previous treatments:
[Health Details]
[Choose One: Email / Phone / In-Person]
Have you utilized similar services in the past? If yes, please explain:
[Previous Services]
How did you hear about us?
[Referral Source]
I acknowledge that all information provided is accurate to the best of my knowledge, and I agree to the terms presented.
[Client’s Signature]
[Date]
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