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Intake Form

Prior to your first appointment, please complete the following Intake Form.

The information will be submitted electronically using encryption and will remain confidential, and not be shared with anyone without your written consent.

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Abma Counselling Services 

Intake Form

Please use this form to provide your therapist with some basic information before your first appointment.

Parents or guardians can complete this form for clients under the age of 16.

Is this a cell phone?

Emergency Contact

Person to notify in case of an emergency

Referral Information

How did you hear about our services?

How can we contact you?

General Information

Tell us a little about yourself

Reason for counselling

Indicate any symptoms you are currently experiencing:

Medical History

Physical Health Information

Thanks for submitting your intake form