Counselling Intake Form Intake Form Full Name * Age * Full Address * Home Phone * Work Phone Email * Emergency Contact Name * Phone * Relationship With You * May we leave a message on phone number provided? * Yes No Send appointment reminders via text? * Yes No Send appointment reminders via email? * Yes No Contact you by email? * Yes No Have you participated in counselling before? * What worked well for you and what did not? Physical History (please be accurate, medical records may need to be disclosed at some point) Annamaya Kosha General Health * Are you now under a doctor’s care? * Yes No If yes, name of doctor Reason for doctor’s care Are you taking any medication? * Yes No If yes, what kind? Reason for medication Last medical examination Have you ever been hospitalized for a physical illness? * Yes No Describe Have you ever been hospitalized for a mental illness? * Yes No Describe Any recent major illnesses or surgeries? * Any recurrent or chronic conditions? * Please enter the following information for any substances including alcohol, tobacco, and drugs that you currently use or have used in the past: Substance Past use (yes/no) Current use (yes/no) How often (per week/ in the last year) What exercise or leisure activities to you currently participate in? * • Activity •Frequency • Length of time Pranayama Kosha What is your typical energy level? * Low High Balanced/Average Sleep (Hours Per Day) * Concerns about sleep? Manomaya Kosha Are any of the following currently concerns for you? Depression Grief Concentration/ Focus Mood Swings Anger / Aggression Worry / Nervousness Social Life Hopelessness Substance Misuse Fear Pain Relationships Vijnanamaya Kosha Education What was school like for you growing up? * Work History Occupation * How Long? * If presently unemployed, describe the situation Hobbies * Anandamaya Kosha Describe your religious or spitirual beliefs * Relationship status * Do you have children? * Yes No Who do you turn to for support? * Any social groups or institutions you are involved in? * Tell anything else in the space below that you think would be helpful for me, as your therapist, to know. Emotional Status Are you currently experiencing strong emotions? Yes No If yes, describe Do you make decisions based on your emotions? * Yes No How well does that work for you? * Did you have what you would consider to be childhood or other traumas? * Yes No If yes, describe Have you been treated for emotional disturbances? * Yes No If yes, when? Have you had any thoughts of suicide? * Yes No If so, when Do you have any thoughts now Present Situation Please state why you decided to come for counselling/therapy? * What is the nature of your situation * What would you like to experience that is different from what you are experiencing now * How long has this been a problem for you * Please state what you would like to work on in therapy * Personal Agreements I understand that I may be asked to do certain “homework exercises” such as reading, changing behaviors, practicing skills, and otherwise acting in my own best interest. I understand that I am entirely responsible for my own actions and I will always make my own final decisions regarding counselling. I further understand that much of the work done will be to resolve issues and will depend on my honesty, and willingness to do the things I need to do to move forward even if it is painful and difficult. I understand that whatever I say in a session is strictly confidential and will not be released to anyone without my consent unless I am violating codes of abuse, harm to myself, or to others. I understand that I will pay in full for appointments not canceled with 24 hours notice. The rate is $140/hr +5%GST. * Yes I Understand Today's Date * As your therapist/counsellor, you honour me by sharing your life and growth with me. I will not hide myself behind silence or position and will have high regard for you as a person. I will bring the best that I know from my study and experience. I will bring you the highest of my insight, wisdom, and support. I will keep a holistic perspective in our work together because I believe that the Physical, Spiritual, and Soul (mind, will, emotions) all work together to form the wholly healthy person. You can expect truth from me even when you may not want to hear it. I will always have compassion and empathy for you in all that we do. I value you as a person in need of care. I will do my best to honour that. Kelly Ranford reCAPTCHA If you are human, leave this field blank. Submit