Intake application 2026

1. Click ‘Get Form’ to open the intake application in the editor.
2. Begin by filling out the 'General Information' section. Enter your last name, first name, birth date, and age. Select your gender by circling either 'Male' or 'Female'.
3. Provide your complete address including street, city, province, and postal code. Include your home, work, and cell phone numbers for contact purposes.
4. In the 'Employment/Education Information' section, indicate your employment status by checking the appropriate box (full-time, part-time, self-employed, or unemployed). Fill in your occupation and length of employment.
5. Circle the highest level of education you have completed from high school to graduate degree.
6. Complete the 'Family Information' section by circling your relationship status and providing details about your spouse/partner if applicable. List names and ages of children.
7. Articulate your concerns that brought you to counseling in the designated area. Be honest about any thoughts of self-harm or harm to others by checking relevant statements.
8. In the 'Medical/Psychological History' section, provide information about your physician and any current medications you are taking. Indicate if you or a family member has received help for substance dependency.

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