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Client Information Form
Identification
*
Indicates required field
Full Name
*
First
Last
Full name
Nicknames or Aliases
*
Gender
*
Male
Female
Date of Birth
*
Age
*
Nationality
*
Height
*
Weight
*
Home Address
*
Relationship Status
*
Single
Married
Separated
Divorced
Widowed
Common Law
Committed Relationship
Cell Number
*
Home Number
*
Email
*
Calls or emails will be discreet, but please indicate any restrictions
*
Emergency Information
In the event of an emergency and we cannot reach you directly, or we need to reach someone close to you, whom should we call?
Name
*
First
Last
Emergency Contact Name
Phone Number
*
Relationship
*
Address
*
Education/Training/Employment
Education Completed
*
Primary
Secondary
College
University
Any Other Training
*
Current Occupation
*
Name of Employment Company
*
Employer Address
*
Family Background
Were you raised by:
*
Single Parent - Mother
Single Parent - Father
Both Parents
Extended Family (Grandparents/Aunt/Uncle)
Other
Please specify other
*
Parents' Marital Status
*
Married
Separated
Divorced
If Separated/Divorced, how old were you?
*
From your perspective, how would you describe your parents' relationship
*
Healthy
Conflictual
Please provide details
*
How would you describe your relationship with your parents?
*
Healthy
Conflictual
How would you describe your childhood?
*
Happy
Unhappy
Are you closer to one parent than the other?
*
Yes
No
If Yes, who?
*
Mother
Father
Please provide details
*
Do you have any siblings?
*
Yes
No
Please provide details, e.g. brothers/sisters, how many:
*
Please complete the following section if you will be engaging in martial/pre-marital counselling or counselling regarding your marriage or relationship.
What type of counselling are you seeking?
*
Premarital
Marriage
Other
Please state:
*
Name of Partner/Spouse
*
First
Last
Name of partner/spouse
Address of Spouse (if different to yours)
*
Contact Number
*
Occupation of Spouse
*
Age
*
Any Children?
*
Yes
No
How many?
*
Religion
*
If yes, are they a product of your current relationship?
*
Yes
No
If Married:
How long have you been married?
*
How old were you when you got married?
*
How old was your spouse when you got married?
*
How long did you know your spouse before marriage?
*
How long did you and your partner date for prior to marriage?
*
Were you engaged?
*
Yes
No
If yes, for how long?
*
Have either of you ever filed for divorce?
*
Yes
No
If yes, Please provide details
*
Were you or your spouse previously married?
*
Yes
No
If yes, please provide details including by what means did the marriage end e.g. death or divorce
*
Is your spouse willing to come to counselling?
*
Yes
No
Uncertain
Have you and your spouse ever been separated?
*
Yes
No
If yes, please provide details
*
Religious and Racial/Ethnic Identification
Current religious denomination/affiliation
*
Which (if any) church do you/did you attend?
*
How often do you attend church?
*
Involvement
*
None
Some/Irregular
Active
Do you believe in God?
*
Yes
No
Uncertain
Do you pray to God?
*
Yes
No
Uncertain
Are you saved?
*
Yes
No
Unsure of what this means
Were you ever prayed for by anyone other than a Christian
*
Yes
No
How often do you read the Bible?
*
Often
Occasionally
Never
Did you ever have your palm read or visited anyone who told you your future?
*
Yes
No
Has there been any recent changes in your religious life?
*
Yes
No
If yes, please explain
*
One a scale of 0 – 5, Please answer the following questions
How important are spiritual concerns in your life?
*
Ethnicity/national origin
*
Race
*
Is there any other way you identify yourself and consider important:
*
Your Medical Care
Your Medical Care
Who is your primary care giver (doctor/clinic)?
*
Phone Number
*
Address
*
How would you rate your physical health
*
Very Good
Good
Average
Declining
Any major health concerns i.e. illness/injuries/disabilities (past or present)
*
Are you presently taking any medication?
*
Yes
No
Please provide details if yes
*
Have you experienced any significant trauma (physical or emotional) which you believe is still impacting you currently?
*
May we contact your medical doctor so that we can coordinate your treatment if deemed necessary?
*
Yes
No
May we contact your former counsellor/therapist for additional information to assist us during our therapeutic if deemed necessary?
*
Yes
No
Personality Information
Which of the following best describe you right now?
Select All that Apply
*
Active
Easy Going
Moody
Nervous
Hardworking
Ambitious
Shy
Often sad
Select All That Apply
*
Likeable
Nurturing
Self-confident
Good Natured
Excitable
Quiet
Submissive
Persistent
Select All That Apply
*
Introverted
Calm
Impatient
Impulsive
Serious
Sensitive
Self-conscious
Have you ever felt like people were watching you?
*
Yes
No
Do people’s faces ever seem distorted?
*
Yes
No
Do colours seem too bright?
*
Yes
No
Are you able to judge distances?
*
Yes
No
Have you ever had hallucinations?
*
Yes
No
Are you afraid of being in a car?
*
Yes
No
Referral
Were you referred by someone or did you self-refer?
*
Referred by someone
Self-referred
If referred by someone, who were you referred by?
Name
*
Relationship
*
Phone
*
Address
*
What was the reason for their referral?
*
Do you agree with the reason of their referral?
*
Yes
No
Uncertain
Reason for Service
Please complete this section if you are a parent referring your child (under 18) to be seen by a counsellor
Name of Child
*
Current Age
*
What is the issue you wish to address with a counsellor with your child?
*
Has your child ever received any form of counselling or form of therapy for this issue before?
*
Yes
No
Please provide details if yes
*
Have you tried anything else to address this issue?
*
Yes
No
Please provide details if yes
*
How do you believe we can help you with this issue?
*
Is there any other information that you wish to share that you believe will be helpful for your counsellor to know?
*
Yes
No
Please provide details if yes
*
Please complete this section if you are seeking counselling for yourself
What is the issue you wish to address with a counsellor?
*
Have you ever had any form of counselling or form of therapy for this issue before?
*
Yes
No
Please provide details if yes
*
Have you tried anything else to address this issue?
*
Yes
No
Please provide details if yes:
*
How do you believe we can help you with this issue?
*
Is there any other information that you wish to share that you believe will be helpful for your counsellor to know?
*
Yes
No
Please provide details if yes:
*
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Home
Services
General In-House Counselling
Corporate Services
Programs & Initiatives
About Us
News & Events
Articles
Contact Us
