Counselling Intake Form

Client contact info

Name **Legal name & what you go by

Street Address *

City *

Province

Phone *

Email address *

Emergency contact

Name *

Phone *

Name

Phone

What is going on for you?

Areas of concern

ADHDAnxietyChronic illness & disabilityConcussionDepressionGrief & lossDivorce & major life transitionsRelationship issuesSelf-careTraumaOther*Check all that apply

What else? Can you tell me more?

Previous counselling, diagnoses or contact with a mental health professional

Medical or physical concerns

Personal Info

Who do you live with?

Gender

Faith or religion

Employment

School or university

Hobbies, interests & activities

Therapy goals

What do you like about yourself?

What do you want to change or achieve in therapy?

How will you know when you've got what you need out of therapy?

Concerns about therapy

Anything else you think might be helpful for me to know

Consent *

I understand that the information I have provided is for therapeutic purposes only and that I am providing it voluntarily. I understand that the data is relayed to my counsellor at the Aclestra Centre and will not be shared with anyone else without my expressed consent.

Please do not fill in this field.

Have a question?

We would like to help, but we can't if we don't know what you are thinking.

So tell us - how can we help?

Convenient scheduling

Online or in-person, daytime, evenings or weekends, in an office or take it outside.

What works for you?

Book an appointment

Learn more

ADHD

Concussion

Counselling

Resources