The Psychotherapy Intake Form Template – Canada is offered in multiple formats, including PDF, Word, and Google Docs. These formats are both modifiable and ready for printing, ensuring they cater to your requirements effortlessly.
Psychotherapy Intake Form Template Pdf – Canada Editable – PrintableSample
1. Client Information 2. Emergency Contact 3. Reason for Seeking Therapy 4. Medical History 5. Current Medications 6. Therapy Goals 7. Previous Therapy Experience 8. Confidentiality Agreement 9. Consent to Treatment
PDF
WORD
Examples
[Client’s Name]
[Client’s ID]
[Date of Birth]
[Address]
[Phone Number]
[Email Address]
[Emergency Contact Name]
[Emergency Contact Phone]
[Relationship to Client]
How did you hear about our services?
[Referral Source]
Please describe the primary issues you are seeking help for:
[Client’s Description of Issues]
Do you have any current or past medical conditions? If yes, please list them:
[Medical Conditions]
Have you ever been diagnosed with a mental health condition? If yes, please specify:
[Mental Health Conditions]
List any medications you are currently taking:
[Current Medications]
What are your goals for therapy?
[Client’s Goals]
I hereby consent to receive psychotherapy services. Signature:
[Client’s Signature]
Date: [Date]
[Client’s Name]
[Client’s ID]
[Date of Birth]
[Address]
[Phone Number]
[Email Address]
How did you find us?
[Referral Source]
What issues or concerns prompt you to seek therapy?
[Issues/Concerns]
Have you participated in therapy before? If yes, please share your experience:
[Previous Therapy Experience]
Please provide details about your family background and social support:
[Family/Social History]
Do you use any substances (e.g., alcohol, drugs)? If so, please elaborate:
[Substance Use]
What are your current stressors? How do you cope with them?
[Stressors/Coping]
What would you like to achieve in therapy?
[Therapy Goals]
I consent to the policies and procedures outlined in this intake form. Signature:
[Client’s Signature]
Date: [Date]
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