Montreal Therapy Centre Intake Form

Online Intake Form

Please be assured that all information
submitted will be kept completely confidential.


*First Name
*Last Name
*Email
*Verify Email
*Address
Address2
*City
*Province/State
 
*Postal/Zip Code
*Country
 
*Home Phone
( )   -
WorkPhone
( )   - Ext.
Cell Phone
( )   -
For reasons of confidentiality, please advise us if we can contact
you and/or leave a message at the numbers you have provided.
Home
Yes No
Work
Yes No
Cell
Yes No
IntakeDate
*Language
English French Other:
*Request For
Individual Therapy Couple Therapy Family Therapy
What is your availability for scheduling sessions?
*Employment
 
Occupation
Date of Birth

Couples (Optional)

Partner's Name
Partner's Phone
( )   - Ext.
Partner's Employment
 
Partner's Occupation
*Gross Family Income
 
*Are you covered by an Insurance plan?
 
Marital Status
 
Referral Source
*In Current Psychological/Psychiatric Treatment
 
*Previous Psychological Treatment
 
If you answered yes to the last question, what was the duration?
*Presenting issues (Check all that apply)
Self-Esteem
Depression
Addiction
Sexual
Relationship-Couple
Eating
Grief
Physical Illness
Sexual Dysfunction
Relationship-Family
Stress
Anger Management
Anxiety
Sexual Orientation
Relationship-Family of Origin
Career/Work Related
Academic
Interpersonal
Please provide a brief description of the current presenting
issue and any other information to help us match you with a suitable professional:

650 characters remaining.
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