Client Intake Questionnaire

Please complete the form in its entirety prior to your first session. All information provided on this form is protected as confidential information. Once you complete this form you will be sent a Client Service Agreement & Informed Consent for signature.

Referred By (If Applicable)

Personal Information:

First Name *

Last Name *

Preferred Name *

Pronouns

Email *

Phone *

Home Address *

City *

Province / State

Postal Code / Zip Code *

Country *

Date of birth *

Age *

Marital Status *

Emergency Contact *

Family Doctor *

Credit Card Information:

A valid credit card number is required to be kept on file.

Credit Card Number *

Credit Card Expiry *

3 Digit Code - CVV/CVC *

History:

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

Yes

Name of Previous Therapist / Practitioner (If Applicable)

Are you currently taking any prescription medication?

Yes

If yes, please list:

Have you ever been prescribed psychiatric medication?

Yes

If yes, please list and provide dates:

General and Mental Health Information:

How would you rate your current physical health?

Please list any specific health problems you are currently experiencing:

How would you rate your current sleeping habits?

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?

What types of exercise do you participate in?

Please list any difficulties you experience with your appetite or eating problems:

Are you currently experiencing overwhelming sadness, grief or depression?

Yes

If yes, for how long?

Are you currently experiencing anxiety, panics attacks or have any phobias?

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain?

Yes

If yes, please describe your current pain:

Do you drink alcohol more than once a week?

Yes

How often do you engage in recreational drug use?

Do you drink smoke or eat or do other activities to excess? Do you consider this to be an issue or non-issue?

Are you currently in a romantic relationship?

Yes

How long have you been in a relationship?

What is your relationship style? List as many as apply (e.g. monogamous, non-monogamous, open relationship, lifestyle, polyamorous, etc.)

On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your current relationship(s)?

What, if any significant or stressful events have you experienced recently?

Family Mental Health History:

Do you have family history of any of the following? Select all that apply

If you answered yes to any of the above, indicate the family member’s relationship to you:

Additional Information:

Are you currently employed?

Yes

If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current work?

Do you consider yourself to be spiritual or religious?

Yes

If yes, describe your faith or belief.

What do you consider to be some of your strengths?

What do you consider to be some of your weaknesses?

What would you like to accomplish out of your time in therapy/coaching?

By checking this box, I consent to receive emails from André Turcotte Psychotherapy related to my account or services I have requested. These messages may include appointment reminders and account notifications among others. Message frequency may vary. All client information is private and secure.

André Turcotte MA, RP, LC

[email protected]

www.a-psych-online.com