IntakeFormNirvanaCounsellingLounge - Nirvana Counselling Lounge

1548 Johnson Street, White Rock, British Columbia, V4B 3Z8, Canada lola.opaciclunot@gmail.com 2365162983

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NIRVANA COUNSELLING LOUNGE

Personal Information

Full Name:

Date of Birth:

Gender Identity:

Preferred Pronouns:

Contact Information/Address:

Emergency Contact (Name, Relationship, Phone Number):

Presenting Issues

What brings you here today?

How long have you been experiencing these issues?

How have these issues impacted your daily life, relationships, and work/school?

What have you tried so far to manage or improve the situation?

Are there specific goals you would like to achieve through counselling?

Mental Health History

Have you ever seen a counsellor, therapist, or psychologist before?

If yes, when and for how long?

What was helpful or unhelpful about that experience?

Have you ever been diagnosed with a mental health condition?

If yes, please specify the diagnosis and date.

Have you ever experienced any of the following:

Anxiety, panic attacks, or phobias?

Depression or persistent sadness?

Trauma or post-traumatic stress?

Suicidal thoughts or self-harm?

Substance use or addiction issues?

Are you currently on any medications for mental health?

If yes, what medications are you taking and for how long?

Physical Health

Do you have any chronic health conditions or medical issues?

Are you currently taking any medications (besides mental health-related)?

How would you describe your sleep patterns?

How would you describe your appetite and eating habits?

Do you exercise regularly?

Family History

Can you tell me about your family structure (e.g., parents, siblings, significant others)?

Are there any significant events in your family history that might be relevant (e.g., divorce, loss, abuse)?

Is there a history of mental health conditions in your family?

How would you describe your current relationship with your family?

Social and Relationship History

Who are the key people in your life (e.g., friends, partner, support network)?

How would you describe your relationships (e.g., supportive, strained, distant)?

Are you currently in a romantic relationship?

If yes, how would you describe the relationship?

Have you experienced any significant losses (e.g., death of a loved one, end of a relationship)?

Education and Work

What is your current employment or education status?

How do you feel about your work or school environment?

Have you experienced any recent changes or stressors related to work/school?

Lifestyle and Self-Care

How do you usually spend your free time?

Do you have any hobbies or activities you enjoy?

How do you typically manage stress?

What does self-care mean to you, and how often do you engage in it?

Reasons for Seeking Help

What motivated you to seek counselling at this time?

Are there specific changes you would like to see in your life?

Are there areas of your life where you feel particularly stuck?

What are your expectations of the counselling process?

How will you know if counselling is helping you?

Final Thoughts

Is there anything else you would like to share that might be helpful for me to know?

Do you have any concerns or fears about the counselling process?

What strengths do you have that you can draw on during this process?

Payment information

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I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

Your information is kept by the clinic for as long as its professional order requires, and your account data for as long as your account is active. A deleted record is permanently purged 45 days after its deletion. Details in our privacy policy.

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IntakeFormNirvanaCounsellingLounge - Nirvana Counselling Lounge

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