Intake | Johnathan Kuipers

The information collected in this form is legally protected and will remain confidential.

Please take your time to answer the questions to the best of your ability / comfort level.

How did you find me?

First name

Last name

Birthday

Gender

Email

Phone

Address

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Sessions take place online via a secure version of Zoom. Do you have any concerns with your ability to join sessions in a confidential space.

Yes

No

Regarding appointment times, are there days or times that work best with your schedule?

Please describe your reason(s) for wanting therapy.

Have you accessed therapy before? If so, for what purpose / goals?

Have you been provided any formal mental health or medical diagnosis? If so, please elaborate to the extent you feel comfortable.

Are you taking any medications or supplements? If so, please provide as much information as possible (name, dose, reason for taking).

Over the past year, have you struggled with or experienced any of the following:

Is there anything else you would like to let me know?

If you have health benefits and would like sessions to be billed directly to your provider (Blue Cross, Green Shield, Medavie, Telus Health, and others), please provide the appropriate details (provider, group, and member numbers) below.

Intake Form