Heidi Spiar M.A., L.M.F.T Private Practice
INTAKE FORM
All clients complete this form prior to/start of service and bring to the first session. If you seek service by tele-counselling (video or phone), follow directions at the bottom to submit the form
Today’s Date____________
                         M/D/YR
Name (including what you like to be called) ________________________________
DOB _________     Age ______      Gender _______  Time Zone ____________
           M/D/YR

Address______________________________ Tel# ________________  Alt#______________

Email______________________  Who do you live with?___________________________

Emergency Contact:  
Name___________________  Address_____________________ Relationship_____________
Phone _________________  Alt#___________________  Email __________________

DESCRIPTION OF PRESENTING PROBLEM

1.	Briefly describe the issues for which you seek counselling?

2.	What steps if any have you already taken to cope with this problem?

3.	How long has this problem being going on? 

4.	Please rate the severity on a scale of 1-10 with 1 being the least and 10 being the most severe.

5.	Have you seen a counsellor before about this problem? 

a.	Did you see a counsellor about another issue in the past? 

b.	Please explain. 

i.	How long did it last?

ii.	Why did you stop?

iii.	What approach was helpful for you in the past?

6.	If you are coming today for more than one issue, list them in priority/what you wish to address.

7.	Describe how your present problem is affecting your relationships, school, work, parenting, and social obligations.

8.	Was there a recent event that led to the issue (example-separation, infidelity, death, loss of job or friend, moving, depression, anxiety)

9.	Have you been told by a health professional or doctor that you have a mental health condition?  When and what?

10.	Are you currently being treated by a psychiatrist, psychologist, or therapist?

11.	Please check all that apply below and briefly comment on severity (out of 10) and length of time it existed or exists:

a.	Overeating
b.	Restless
c.	Obsessiveness
d.	Compulsiveness
e.	Alcohol or other drug use
f.	Depressed mood
g.	Frequent crying
h.	Difficulty concentrating
i.	Difficulty with sleep/nightmares/decreased need for sleep
j.	Fears or phobias
k.	Lack of motivation
l.	Indecisiveness
m.	Anxiety
n.	Moodiness
o.	Anger
p.	Aggressiveness or acting out
q.	Social withdrawal
r.	Feelings of worthlessness
s.	Fatigue or loss of energy
t.	Problems at school or work
u.	Problems with peers
v.	Housing problems
w.	Couple or family relationship trouble
x.	Experienced trauma
y.	Financial trouble / housing
z.	Other
12.	If possible, describe what led you to come today?
13.	What coping or stress reduction strategies have worked for you in the past?

14.	When was your last physical exam?  

15.	Describe any medical condition that could affect or is affected by the reason you seek counselling.

16.	Please provide the name and location of any another health practitioner such as a chiropractor or massage therapist that you currently see? 

17.	List any past medical or psychiatric diagnosis. Were you ever hospitalized and when?

18.	Have you experienced emotional, physical or sexual abuse/assault?

19.	Have you or anyone else ever been concerned that you may have a drinking or drug problem? Gambling or gaming? Eating disorder?

20.	Do you identify with LGBTTQQ? (Lesbian, Gay, Bi-sexual, Trans, Queer, Questioning)

21.	Do you identify as First Nations, Inuit or Metis?

MEDICATION AND SUBSTANCE USE

1.	If applicable, list medications/supplements/herbs you take or have taken in the last three months.

2.	What amount of caffeine drinks do you drink each day?

3.	Do you smoke and if so, how much?

4.	If you use/smoke marijuana, how much and in what kinds of situations?

5.	In the last month, how many alcohol drinks have you consumed each day? 

a.	Is there a general time you usually drink more than others? (i.e., weekends). One drink=12 oz beer, 4 oz wine or 1 oz hard liquor

6.	How often do you use alcohol or drugs to manage stress? 

a.	Change a bad mood or relax? (never/2-3 x a month, once/month, once/wk/ more than once/wk, ev other day, daily?

7.	How often do you gamble? 

8.	How often do you play video games/for how many hours?

FAMILY INFORMATION

1.	What is your marital status? (living with, married, separated, widowed, divorced, etc.)

2.	Are you currently in a relationship and if yes, rate it out of 10 with 1 being the least happy and 10 being the most happy.

3.	Is your partner/spouse currently in a job that takes him or her away from the family (military, jail, work travel)?

4.	Do you have children? How many and what age? Where do they live? Do you share custody?

5.	Are your parents still living and what is your relationship?

6.	Were your parents married? If divorced, what reasons do you now of that led to the break up?

7.	Do you have siblings and what is your relationship?

8.	Have any of your family members had problems with the following: (indicate if sibling, parent or grandparent)

a.	Alcohol or other drugs
b.	Depression
c.	Anxiety
d.	Other mental health
e.	Suicide or homicide
f.	Overeating/eating disorder
g.	Obsession or compulsion
h.	Criminal activity
i.	Gambling or gaming
j.	LGBTTQQ (Lesbian, Gay, Bi-sexual, Trans, Two-spirit, Queer, Questioning)
k.	Youth at risk
l.	School problems or identification
m.	Abuse or violence

9.	Of your family or friends, who do you count on for emotional support?

10.	What community groups, clubs or recreation do you count on for support? How often?

11.	Do you belong or identify with a religious community?

12.	Complete this sentence: When I am finished with counselling, I will be able to…

Please feel free to share anything else you believe will help your counselling experience.

Choose one of the follow ways to submit the form

1.	Bring to the first session or drop off at office beforehand or mail to Heidi Spiar
 Moore Chiropractic Clinic 121 Main Street N. Markham, Ontario L3P 1Y2

2.	Print the agreement from the web page, complete, sign and fax to: 905 471-2495

3.	Complete the form, save it, email as an attachment to Heidi@heidispiar.com. This option does not require a signature

4.	Complete and sign the form, copy and paste it into an email message to Heidi@heidispiar.com. This option does not require a signature