First Name  *

Last Name  *

Email Address  *

Confirm your email address  *

Cell Phone Number

Home Phone Number  *

How do you prefer to be contacted?  * Email  Cell Phone  Home Phone 

Address

City

Province/State

Postal Code / Zip

Country

Age

Gender  Male   Female 

Current Living Arrangement

Current occupation If none, please describe your typical day.

Level of Education  Elementary School
 Some High School
 High School Graduate
 Some College
 College Graduate
 Advanced Degree

Have you ever received counselling, psychological, or psychiatric services?  Yes   No 

If yes, why did you seek treatment and for how long?

Do you have any medical problems?  Yes   No 

If yes, please list them.

Do you take any medications?  Yes   No 

If yes, please list names and dosages.

Choose the service you would prefer  Online Session   Telephone Session   In Office Session 

Why have you decided to see a therapist? Please describe any problems you would like us to help you with. Use as much space as you need.

I have read and agree to Client Information and Statement of Understanding.  *