Intake Form – Teen - Compass for Life - Gayle Saifert D.C.S, RSWCompass for Life

Client Information

Client name: *

Gender: *

Date of Birth: *

day

/

month

/

year

School:

Mailing address:

Street Address City State / Province / Region Postal / Zip Code Country

Home #:

Business #:

Cell #:

Email: *

Emergency contact:

Address:

Street Address City State / Province / Region Postal / Zip Code Country

Home #:

Cell #:

Business #:

Email:

Which email address should be used for billing purposes:

Others that reside at your address

Name:

Relationship / age:

Name:

Relationship / age:

Name:

Relationship / age:

Name of Family Doctor:

Telephone #:

Address:

Street Address City State / Province / Region Postal / Zip Code Country

Name of Treating Psychiatrist (if applicable):

Have you ever been diagnosed by a physician or psychiatrist with ADD, Learning Disability or any other mental health diagnosis? If so please elaborate.

Are you taking any medications? If so please provide details including prescribing physician.

Why are you are seeking treatment (please include when the problem began):

Please rate any issues you may be struggling with:

Anxiety

Past or present?

Text1

Panic

Past or present? (1)

Text1(1)

Phobia

Past or present? (1)(1)

Text1(1)(1)

Sadness

Past or present? (1)(1)(1)

Text1(1)(1)(1)

Irritability

Past or present? (1)(1)(1)(1)

Text1(1)(1)(1)(1)

Poor Concentration

Past or present? (1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)

Relationships

Past or present? (1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)

Self Harm

Past or present? (1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)

Binging / Purging / Food Restrictions

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)

Appetite Change

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)

Anger

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Suicidal Thoughts

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Social Withdrawal

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Alcohol Use

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Recreational Drug Use

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Prescription Drug Use

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Sleep Issues

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Fatigue

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Use of Sleep Aids

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Change in Appetite

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Poor Relationships

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Self Injury

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Risky Sexual Behaviour

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Problems at Work

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Intrusive or Unwanted Thoughts

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Compulsive Behaviours

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Rituals that seem to be unusual or are interfering with day to day functioning

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Any other concerns:

Any other concerns

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Please list any helping professionals you have been involved with. (Include dates and any current involvement)

Name of Practitioner

Date

Outcome

Name of Practitioner

Date

Outcome

Name of Practitioner

Date

Outcome

Name of Practitioner

Date

Outcome

Name of Practitioner

Date

Outcome

Do you have a history of self harm, (cutting, eating disorder, suicidal thoughts or attempts?)

Please describe your primary relationships (how do you get along with friends and family)

What are your hobbies?

How would you describe your strengths?

Have you noticed anything that provides relief from your presenting concerns?

Is there a history of mental health or substance issues in the family, (if so, please provide details)

Please list how you hope the treatment will help

Additional Information In the space below, please share any other details that would help me understand you better.

Electronic Communication

The use of electronic communication is used primarily for the purpose of billing and coordinating contact. The transmission of information via email or text may unintentionally limit the protection of confidentiality. More specifically, networks are not secure, emails are not encrypted and emails can be sent to unintended recipients without the sender’s intent. Given these risks, I agree to use email to communicate for billing and the purpose of coordinating contact.

Initials*

How did you find me?*

I consent collecting this data and processing it according to Privacy Policy of this website.

Intake Form – Teen

Client Information

(416) 333 – 0640

gayle@compassforlife.ca

Linkedin

© 2014 Compass for Life. Gayle Saifert D.C.S, RSW
Website by Young Seagull

Intake Form – Teen

Client Information

(416) 333 – 0640

gayle@compassforlife.ca

Linkedin

© 2014 Compass for Life. Gayle Saifert D.C.S, RSW Website by Young Seagull

© 2014 Compass for Life. Gayle Saifert D.C.S, RSW
Website by Young Seagull