ABMA COUNSELLING SERVICES
Confidential Client Information Form
Please use this form to provide your therapist with some basic information before your first
appointment. The information is confidential and will not be shared with anyone without
your written consent.
Today’s Date:
Name of Client:_____________________________ DOB: _________ Age: _______
Guardian Name (if applicable): _______________________________
Address: ___________________________________ Postal Code: ______________
Phone: _______________________ Email: _________________________
Emergency Contact:
Person to alert in the event of a medical emergency: __________________________
Relationship to you:_________________________ Phone: ____________________
Family Doctor: _____________________________ Phone: _________________
Referral Information:
Referred by: Internet search _____ Other (please specify): ______________________
General Information:
Current Occ
upation/Studies: ____________________________________________
Relationship Status: ____________________________________________
Name of Spouse/Partner: _____________________ Years in relationship: _____
Children (name/age): __________________________________________________
Reason For Counselling:
What main concern would you like to address in therapy? ______________________________
____________________________________________________________________________
____________________________________________________________________________
How has this affected your life? __________________________________________________
____________________________________________________________________________
____________________________________________________________________________
How long have you been experiencing this challenge? ________________________________
List any strategies you’ve used to try to cope with/overcome this challenge: ________________
____________________________________________________________________________
____________________________________________________________________________
Symptoms:
Indicate “Yes” if you have you experienced any of the following:
Current Past
Depressed m
ood ______ _____
Anxiety ______ _____
Phobias ______ _____
Panic attacks ______ _____
Angry outbursts ______ _____
Sleep disturbances ______ _____
Memory loss ______ _____
Overuse of alcohol ______ _____
Overuse of food ______ _____
Addictions (______________) ______ _____
Suicidal Thoughts ______ _____
Intrusive thoughts (obsessions) ______ _____
Obsessive behavior
s ______ _____
Mood swings ______ _____
Hallucinations ______ _____
Frequent body complaints ______ _____
Body image problems ______ _____
Intrusive memories ______ _____
Loss of appetite ______ _____
Social withdrawal ______ _____
Other __________________ ______ _____
Medical History
Have you had previous psychological care or counselling? If yes (a) when and (b) describe the
reason for seeking counselling previously: _________________________________________
___________________________________________________________________________
Have you ever received a diagnosis for a mental health-related concern? If yes, what was
the
diagnosis? __________________________________________________________________
Please provide the name and dosage of any medication you are taking:
____________________________________________________________________________
____________________________________________________________________________
Have you ever been hospitalized for psychological problems? If yes, when?
____________________________________________________________________________
____________________________________________________________________________
Have you had any s
ignificant or traumatic experiences that cause you concern at this time?
____________________________________________________________________________
____________________________________________________________________________
If applicable, please note any addictive behavior (e.g. alcohol/substance abuse) and/or mental
health concerns (e.g. depression/anxiety) in your present family or family of origin:
____________________________________________________________________________
____________________________________________________________________________
Physical Health Information
Do you have any medical conditions that are affecting your daily life:(ex. chronic illness, chronic
pain, traumatic injury, severe allergies, surgeries). Please provide dates when possible:
____________________________________________________________________________
____________________________________________________________________________
List any past physical health concerns:
____________________________________________________________________________
____________________________________________________________________________
List current medications (if any):
____________________________________________________________________________
____________________________________________________________________________
Have you ever been in an automobile accident or head injury that is contributing to your current
condition? Describe:
____________________________________________________________________________
____________________________________________________________________________
Is there any other information about yourself or your life circumstances that is important for us to
know?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Thank you for completing this Intake Form. Click Submit to send the form.
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