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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