Intake Form for Counselling

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Advance Minds Patient Intake Form

Name

Address

Date of Birth

Gender

Phone

Current Medications

Mental Health History

Substance Use

Legal Information

Occupation

Living Situation

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Address

Relationship to Patient

Additional Comments

Consent & Agreements - I consent to receive treatment. I acknowledge confidentiality and privacy policy. I authorise sharing information with other health providers when necessary. I consent to SMS/email reminders

Yes

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What our clients think

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We would like to acknowledging the Traditional Owners and Custodians of the land, the people of the nation, and pay our respects to their Elders past and present, as well as to emerging leaders.