The Psychosocial Intake Form is designed to gather comprehensive information about your psychological, social, and emotional well-being. This information will help us understand your current situation, and tailor our services to you. Please complete all fields, if a field does not apply you may enter ‘N/A’; If you have any questions or need assistance while completing the form, please do not hesitate to contact our office for support.

Please note the following:

  • A signature is required, which you can do easily from any mobile device, tablet or computer.
  • Fields do not save and the form must be completed in one sitting. It will take about 10 mins to complete.
  • If you are in a partnership each person is to complete their own form.
  • Click Submit when done.

 

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Personal Information

Full Name
Partner's Name: This is needed to ensure your files are linked before your session. If you are a single applicant, please write 'N/A"
Address

History and Personal Information

To assist your Therapist in preparing for your consultation. Please complete all fields, put N/A if not applicable.
Please describe your childhood family experience?
Please select one
Indicate name, dose and purpose
Marital Status
What is your current occupation and educational history?
How would you describe your social interaction
Are you involved in any custody, access dispute, disagreement or any legal difficulties
What is your stress level?
How would you rate your physical health?
Do you drink alcohol?
Do you use recreational substances?
Do you have concerns about your substance use?
Current Symptoms: Please select all that are relevant today.

CONSENT 

Psychosocial Interventions 

Consent to Engage in Professional Social Work Services

This document represents my voluntary and informed consent to participate in professional social work services, specifically within the context of a psychosocial interview.

  • I acknowledge that I may withdraw from social work services at any time. I also understand that all information and records will be maintained in a secure and confidential manner.
  • I understand that if I was referred by a third party (e.g., a fertility clinic or consultant agency), a summary report will be prepared following my session with Your Counselling Ltd. This report will be shared with the referring party. Once transmitted, the summary report becomes the property of the receiving clinic or agency, and any further disclosures will adhere to their policies.
  • I understand that Your Counselling Ltd. does not retain formal copies of the summary report, keeping only intake notes and relevant information. The summary report will be sent to the clinic or agency as a PDF document attached to an email. I release Your Counselling Ltd. from any liability associated with the electronic transmission or disclosure of this report.
  • I understand that any fees for services will be discussed and agreed upon prior to the session.
  • I understand that if I wish to obtain a copy of the summary report, I must request it directly from the referring agency or clinic, following their established processes and procedures.
  • By placing my electronic signature below, I acknowledge that it holds the same validity as a signature provided in person. I also understand that this consent will be reviewed verbally before any social work intervention begins. I confirm that I can raise any questions about this consent prior to the interview.
Clear Signature
Upon signing, you are indicating that you have read and understood this consent form. You agree to accept the services as detailed above.