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Intake Form

How would you like us to

use the information below?

Any Message Is

Fine

Appointment

Reminders Only

Worksheets and other documents

(password protected)

Skill

Coaching

What Difficulties Do You Hope To Address in Therapy?

Please check all that apply

General anxiety / restlessness

Poor self-esteem

Difficulties with making decisions

Thoughts of suicide

Postponing / Procrastination

Health anxiety or fear of having a serious illness

Difficulties with adjustment after traumatic events (accidents, assaults)

Depression

History of abuse

Loss / grief

Family of origin issues

Borderline personality disorder

Body focused behaviours (e.g., skin picking)

Anxiety about social situations

Lack of assertiveness

Difficulties with aggressive behaviour

Intrusive thoughts or obsessions

Worry thoughts

Difficulties with relationships

Addictions

Panic attacks

Isolating yourself

Feeling angry or irritated

Self-harming behaviours that are not meant to end in death

Adjustment to physical illness

Obsessive compulsive disorder

Adjustment to changes in life circumstances (move, loss of job, divorce etc.)

Other Difficulties

Treatment History

Have you been given a psychiatric diagnosis?

Are you taking any psychriatric medication?

Did you try to get help for your difficulties before? Please check all that apply

Hospitalization(s)

Received general counselling

Received cognitive behaviour therapy (CBT)

Received dialectical behaviour therapy (DBT)

Support from family physician

Was seen by a psychologist

Attended groups

Was seen by a psychiatrist

Tried therapy other than CBT or DBT

Used self-help materials

List The Medication

What are your goals for therapy?

Your Signature

Phone

Other Phone

Thanks for submitting!

First Name

Phone

Let me know if you have any questions or want to book a consultation or a regular appointment

Thanks for submitting! I will make sure to get back to you within 24 hours.Joanna

4275 Village Centre Court

Lower Level 02

Mississauga, Ontario

416-550-1072

Joanna@VillageCentreCBT.net

Access Online Appointment

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