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HOME
TEAM
ACUPUNCTURE & MASSAGE
COOL LASER THERAPY
SHIATSU MASSAGE
COUNSELLING
TELE-COUNSELLING
TAI-CHI and QIGONG
MINDFULNESS
CONTACT
Courtland Acupuncture
BOOK AN APPOINTMENT
COUNSELLING INTAKE FORM
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Phone
(###)
###
####
Date of Birth
MM
DD
YYYY
Main Occupation (work or other)
Hobbies
Relationship Status (single/married/partnered)
If Applicable Rate Relationship Health with Your Partner/ scale 1-10
1
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9
10
Do you have children?
Rate overall family relationships /scale 1-10
1
2
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5
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9
10
How many hours do you work per week? Including in the home if you work at home.
How would you rate your childhood if 0 is terrible and 10 is wonderful?
0
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5
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9
10
Describe your sleep habits and any issues with waking or dreaming
List your main reasons for coming to counselling
List any other past or present health concerns
List prescription medication being taken if relevant
Check other life issues that apply to you or what's troubling you
communication problems
hopelessness
pain
insecurity
self harm
confusion
disorganization
anger issues
feeling numb/unreal
negativity
resentment
guilt
anxiety
fear
stuck in a rut
lack of joy/fun
too busy
feeling disoriented
not understanding what people want from you
manipulation/lying
losing time
forgetting promises, appointments, or things you've said/done
goal setting
trouble in relationships
fear of change
self esteem
violence
criminal activity
obsessions
hearing voices
not feeling in control
addiction
grief
mood swings
diet/nutrition
exercise
controlling behaviour
apathy
irresponsibility
hatred
ability to love
racing thoughts
rage
suppressed feelings
lack of intimacy (physical and/or emotional)
illness
sense of belonging
loneliness/isolation
trauma
flashbacks
suicidal thoughts
trouble focussing
social problems
boredom
depression
not feeling accepted
identity issues
Is there anything you'd like to say about things you've checked off above?
What foods/alcohol/drugs do you take that aren't good for you?
What role does exercise play in your life?
How many coffee or caffeine drinks do you have per day?
What types of doctors/practitioners/counsellors have you been involved with?
What percentage of your food is home cooked?
How would you describe your relationship with food?
What do you do for fun?
How do you relax?
What do you look forward to in life?
Have you ever feared for your life?
Is there anything you've done that you would undo if you could?
How happy are you with your job/vocation?
Have you ever been hospitalized?
What is your best quality as a person?
What is your worst quality/habit?
What do you feel your life purpose is?
Is there anything you worry about often?
Is anything about your life out of control?
Rate the following on a scale from 0-10
usual stress level
0
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5
6
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8
9
10
usual energy level
0
1
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5
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9
10
support
0
1
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9
10
abilty to relax
0
1
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5
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10
self love
0
1
2
3
4
5
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9
10
self hatred
0
1
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4
5
6
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8
9
10
anxiety
0
1
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4
5
6
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8
9
10
moodiness
0
1
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4
5
6
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8
9
10
contentment
0
1
2
3
4
5
6
7
8
9
10
addiction
0
1
2
3
4
5
6
7
8
9
10
joy
0
1
2
3
4
5
6
7
8
9
10
fear
0
1
2
3
4
5
6
7
8
9
10
shame
0
1
2
3
4
5
6
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8
9
10
patience
0
1
2
3
4
5
6
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8
9
10
anger
0
1
2
3
4
5
6
7
8
9
10
excitement
0
1
2
3
4
5
6
7
8
9
10
fulfillment
0
1
2
3
4
5
6
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8
9
10
love
0
1
2
3
4
5
6
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8
9
10
What, if anything, do you feel stands in the way of your satisfaction with life?
If you had no physical, emotional, or monetary boundaries in life, what would you do?
When you reflect on your life, are there any repetitive themes worthy of note (positive or negative)?
Is there anyone in your life you wish you had a better relationship with?
If the rating 10 is a whole, balanced, content person, and 0 is not coping at all, where do you rate yourself:
TODAY
0
1
2
3
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5
6
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8
9
10
A MONTH AGO?
0
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7
8
9
10
A YEAR AGO?
0
1
2
3
4
5
6
7
8
9
10
Is there anything else you'd like to say about yourself or your overall health/wellness?
Thank you!