Adult Intake Form



Please fill out this information form as carefully and as thoroughly as possible. The information you provide protected as confidential information.
If for any reason you do not feel comfortable completing any of the information in the form please let your therapist know


Please do not include phone numbers at which you do not wish to be contacted.

Emergency Contact


Current Marital Status (Check one of the following)

Family Information

Medical Information

Psychological Information

Have you ever received psychotherapy, counselling, or other treatment for personal and/ or marital problems ?