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Mind Multitudes

Mind Multitudes

MENTAL HEALTH & WELLNESS CLINIC

Client Intake Questionnaire

Please fill in the information below and bring it with you to your first session.
Please note information provided on this form is protected as confidential
information.

Contact us

May we leave a message?
Yes
No
May we leave a message?
Yes
No
May we leave a message?
Yes
No
Marital Status:
Never Married
Domestic Partnership
Married
Separated
Divorced
Widowed

Health and Medical History

Previous therapist/practitioner
Yes
No
Are you currently taking any prescription medication?
Yes
No
Have you ever been prescribed psychiatric medication?
Yes
No

General and Mental Health Information

How would you rate your current physical health?
Poor
Unsatisfactory
Satisfactory
Good
Very good
How would you rate your current sleeping habits?
Poor
Unsatisfactory
Satisfactory
Good
Very good
Are you currently experiencing overwhelming sadness, grief, or depression?
Yes
No
Are you currently experiencing anxiety, panics attacks or have any phobias?
Yes
No
Are you currently experiencing any chronic pain?
Yes
No
Do you drink alcohol more than once a week?
Yes
No
How often do you engage in recreational drug use?
Daily
Weekly
Monthly
Infrequently
Never
Have you experienced any suicide ideation or self-harming attempts?
Yes
No
In addition to counselling practices we offer in-person one-on-one meditation practice. Would you be interested in participating in mindfulness meditation classes or restorative yoga?

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

Alcohol/Substance Abuse
Yes
No
Anxiety
Yes
No
Depression
Yes
No
Domestic Violence
Yes
No
Eating Disorders
Yes
No
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