Intake Form - North Durham Professional Counsellors

*Please note that as of May 26, 2025, North Durham Professional Counsellors will be at a New Location,
The address of this new location is 175 North Street, Suite 101, Port Perry, ON L9L 1B7*

Contact us to inquire:

905-985-1130

905-985-6374

Info@northdurhamcounsellors.com

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Intake Form

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Intake Form

Intake Form

Completion of this form will place you in our system and on our wait-list
Date*
Client Information
Client’s Name*
Date of Birth*
Gender Identity
- Male
- Female
- Non-binary
Prefer to self-describe
Decline to answer
Preferred Pronouns
- He
- Him
- His
- She
- Her
- Hers
- They
- Them
- Theirs
Prefer to self-describe
Decline to answer
Person Completing Form (if different than client)
Home phone (if available)
Voice message O.K.?
- Yes
- No
Cell Phone
Voice/Text Message O.K?
- Yes
- No
Street Address
Town/City
Postal Code
Email Address
Message O.K?
- Yes
- No
Referral Source
Any family members/partners receiving services at NDPC?
- Yes
- No
Family Physician & Phone Number*
Emergency Contact (name, relationship, address, phone #)
Availability
Preference for appointment style
- In-Person
- Online/Virtual
- Phone
Which days are you available*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Which times are you available*
- Mornings
- Afternoons
- Evenings
Additional Information
Have you received previous services at NDPC or elsewhere?
- Yes
- No
Main concerns and the reasons for requesting counselling or an assessment at this time (please check all that apply)?
- Depression/Mood Disorder
- Relationship/Interpersonal Issues
- Trauma
- Anxiety/Panic Disorder
- Health Anxiety
- Social Anxiety
- Phobia
- Post-traumatic Stress
- Stress Management
- Auto Accident
- Work-Related Injury
- Post-Partum
- Self-Esteem
- Family Origin Issues
- Bereavement/Loss
- Family/Relationship Violence
- Work/Career Issues
- Parenting
- Separation/Divorce
- Behavioural Issues
- Health, Medical, or Pain
- Attention Deficit-Hyperactivity Disorder
- Major Life Changes
Additional Details:
What are your main goals for counselling? What would you like to achieve by attending services at NDPC?
Do you have preferences for your clinician (example: male or female)?
Please indicate if you have insurance coverage for services (Please note that with few exceptions, we do not bill for services directly. The responsibility of payment for all invoices remains with you, independent of any third-party coverage. You are responsible for inquiring about and managing your coverage. However, if you provide your coverage information, we can try our best to assign you to the suitable clinician.)
- Registered Psychologist
- Registered Psychotherapist
- Therapist under supervision of Psychologist/Psychological Associate
- Auto Insurance
- WSIB
- Non-Insured Health Benefits for First Nations
- No insurance coverage
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Contact Us

175 North Street, Suite 101,
Port Perry, ON - L9L 1B7
905-985-1130
905-985-6374
Info@northdurhamcounsellors.com

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