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 Spanish Other:
*Request For
Individual Therapy Couple Therapy Family Therapy
What is your availability for scheduling sessions? Please
indicate all times during which you are available for scheduling.
Be as specific as possible. Eg. Mondays: morning, afternoon, evening, etc:
*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.
Verify Authentication Code: