Name
*
First Name
Last Name
Name of Additional Client (if applicable)
Age (if under 19)
Marital Status
*
Never Married
Common Law
Married
Separated
Divorced
Widowed
Birth Date
*
MM
DD
YYYY
Gender
Male
Female
Prefer not to say
Home Phone
(###)
###
####
Cell Phone
(###)
###
####
May we leave a voice message at this number?
Email
*
May we email you?
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you hear about us?
Friend / Family
Internet Search
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Services Seeking
*
Briefly describe the concerns you are seeking help for
Have you previously seen a counsellor at Anchor Counselling & Wellness?
*
If yes, please list the counsellor's name
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Have you ever been prescribed psychiatric medication?
If yes, please list current medication
Have you experienced or are you currently experiencing events that you consider to be mentally, emotionally, and/or physically traumatic?
If yes, please describe
Please list any significant life changes or stressful events that you have experienced recently
When could you be available for an appointment?
*
You can add more detail here
In matching you with a therapist, do you have any preferences you would like us to consider?
Do you have extended health insurance coverage for the counselling services?
*
Please check with your insurance carrier to see if they cover Registered Clinical Counsellors (RCC), Registered Marriage & Family Therapists (RMFT), or Canadian Certified Counsellors (CCC)
