INTAKE FORM

General Information

Are you answering on behalf of yourself or someone else? *

SelfSomeone else

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Your relationship to the client

Spouse/PartnerBoyfriend/GirlfriendParentFamily MemberFriendCaseworkerSocial workerOther: (specify)

Other:

Your name

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Client first name

Client last name

Date of birth

Email Address

Home phone

Mobile phone

Home address

How did you find out about us?

How easy was it to reach us

12345

Where 1 is "not at all easy" and 5 is "very easy"

Where would you have gone if you didn't come here for services? (check all that apply)

Doctor's officePsychiatristWalk-in medical clinicWalk-in mental health clinicHospital emergency roomOther physical health providerOther mental health providerFamily/friendNowhereOther: (please specify)

Other:

Which ONE would you have been MOST LIKELY to use?

Doctor's officePsychiatristWalk-in medical clinicWalk-in mental health clinicHospital emergency roomOther physical health providerOther mental health providerFamily/friendNowhereOther: (please specify)

Other

How long have you been waiting for services from us?

How long have you been waiting for other services?

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Work Information

Current work status

EmployedRetiredNot workingLight Duty

Occupation

Health Information

What brought you here? What are the reasons for your visit? *

Have you attempted to access any other services prior to coming here? *

YesNo

Which services did you attempt to access? (please list)

Have you seen a treatment provider in the past for these conditions? *

YesNo

Treatment Provider *

Date (approximate) *

Treatment *

 

 

 

 

 

 

 

 

 

What was your experience with these other services? Did they help?

Have you ever visited a hospital emergency room for the condition(s) that brought you here? *

YesNo

On average, how many times a year do you visit the emergency room due to the condition(s) that brought you here? *

In the past year, how often have you visited the emergency room as a result of your condition(s)? *

NeverOnceTwiceThree to four timesEvery month or twoMore often than once a month

Please list any medications you are currently taking

Medications

Dose

 

 

 

 

Please list any allergies

Allergy

Severity

 

 

 

 

Please list any surgeries

Surgery

Date

 

 

Do you consume alcohol?

NeverDailyOnce a weekOnce a monthOnce a year

Do you use cannabis?

NeverDailyOnce a weekOnce a monthOnce a year

Do you smoke?

YesNoI used to smoke

Do you vape?

YesNoI used to vape

Do you use recreational drugs?

NoI have previously usedI currently use

Consent

I confirm that above information I have provided is true, complete and accurate. *

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