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Primary Contact Name:*
Address:*
City:*
Province:*
Postal Code:*
Phone (Home):
Phone (Cell):*(only one phone required)
Phone (Work):
Email:*
Nature of Concern:*	Individual IssuesAnger Anxiety Depressive Symptoms Family of Origin General Health/Disability Grief/Loss Medical/Psychiatric issues Mid-Life Crisis Self-Esteem Sexual Orientation/Identity Stress Safety Planning Suicidal Ideation Family IssuesAddiction-related Adolescent Issues Adult Child Issues Blended Family Child Issues Extended Family Relationship/Marital Issues Separation/Divorce Work-Related IssuesWork Attendance Balance – Family and Work Career Conflict Harassment Interpersonal Occupational Change Occupational Stress Performance Retirement Workload Traumatic IssuesAbuse (Current – Not DV) Abuse (Historical- Not DV) Domestic Violence Robbery Stranger-related Assault Suicide Victim of Crime Workplace Accident Addiction IssuesAlcohol Drug Eating Disorder Gambling Internet Sexual
Type of Therapy:*
Choose your therapist:*
How did you hear about us:*
Referral Source Details:	eg) name of professional referral or promo code
Group/Course Name:*

Please list the client name(s): (Date of Birth should be entered as MM/DD/YYYY)*
1):
Name:	Same as primary contact?
DOB:
Sex:
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If service is sought for a child or adolescent, please complete the following additional information and check this box:
Yes, this is for a child or adolescent
Full name of child or adolescent:
DOB of child or adolescent:
Mother's Name:
Father's Name:
Are the parents:
Custody Arrangement:*
A copy of legal custody documents is required for a child/adolescent file to demonstrate sole custody, before therapy can commence. If custody is shared - consent is required by both biological parents.
Mother's Contact Information:	Same as primary contact?
Address:
Phone:
Email:
Father's Contact Information:	Same as primary contact?
Address:
Phone:
Email:
Parent Financially Responsible for Therapy:


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