Confidential Counselling Intake Form printable pdf download

CONFIDENTIAL COUNSELLING INTAKE FORM

The Intake Appointment is to assess your current concerns and recommend

the most appropriate treatment options which may include on-going counsel-

ling

Please provide the following information.

Name: __________________________________ ____________________________________

(Last name)

(First name)

Birthdate (DD/MM/YY): ____________________

Male/Female___ Student #:______________________

Phone: (____) _____________ Can we leave a message? Y ___ N ___

Email: ________________________ Where do you live now? off-campus _____on-campus _____

Residence: Bldg.______________ Floor___________

Year______

Program_____________________ Are you an international student? Y ___N ___

Referred for counselling by: Self ___ Medical Staff at Health Services___ Carleton Faculty or Staff___

Friends___ Family___ Residence Life Staff___ Other ____________________________

Your resources: Do you have access to extended health insur ance, or other means of paying for pr ivate

counselling off-campus? (Please circle one)

Yes

Not Sure

Other Resources: Social Networ k___ Family___ Spir itual___ Other ___

Reason(s) for seeking counselling: What ar e your concerns? ________________________________________

____________________________________________________________________________________________

Your counselling history: Have you had any past counselling experience?

Yes ___

No ___

Are you currently seeing anyone (eg. doctor, alternative therapist) ______________________________________

Please provide us with an alternate contact:

Name: ________________________________ Telephone: (____) __________________

**PLEASE NOTE***

All counselling services at Health & Counselling Services are CONFIDENTIAL – some exceptions to confidenti-

ality include legal requirements, such as if a client is in danger of harming themselves or others or if they report

current child abuse. Health & Counselling Services has a no-show / late cancellation policy. If you need to miss a

session for any reason, we need a minimum notice of 24 business hours to cancel. Failure to notify us of cancella-

tion or failure to come for your appointment will result in a $100 charge which will be placed on your student ac-

count.

Signature: ________________________________ Date:_______________________________

09/2015

Confidential Counselling Intake Form