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.
Emergency Contact
Person to notify in case of an emergency
Referral Information
How did you hear about our services?
General Information
Tell us a little about yourself
Reason for counselling What main concern would you like to address in therapy?
Indicate any symptoms you are currently experiencing:
Medical History Have you had previous psychological care or counselling? If yes (a) when and (b) describe the reason for seeking counselling previously:
If applicable, please note any addictive behavior (e.g. alcohol/substance abuse) and/or mental health concerns (e.g. depression/anxiety) in your present family or family of origin:
Physical Health Information Do you have any medical conditions that are affecting your daily life: (ex. chronic illness, chronic pain, traumatic injury, severe allergies, surgeries). Please provide dates when possible:
Is there any other information about yourself or your life circumstances that is important for us to know?
Submit
Thanks for submitting your intake form
