Intake Form For Counselling Appointment

The information below is only viewed by me (Dr. Kasim Al-Mashat) and is confidential. As a Registered Psychologist, I adhere to the highest standards of practice.

Full Name *

Email *

Phone

What is your date of birth (Day/Month/Year)? *

Is it okay to leave you a voicemail on the phone number you have listed (if needed)? *

Yes No

Address (Street or unit, city, and postal code) *

How did you hear about this? (Please specify) *

What is the primary reason(s) for seeking counselling at this time? *

How serious do you consider your present concern(s) *

Mild Moderate Severe Extremely Severe

How optimistic are you that your concern(s) can be resolved? *

Pessimistic Mildly optimistic Moderately optimistic Strongly optomistic

Do you take prescription medication? If yes, please list. Otherwise, indicate 'not applicable' *

Have you experienced any recent significant life changes or stressful events? *

Yes No

If you answered 'yes' above, please describe briefly. Otherwise, indicate 'not applicable'.

Any previous overnight hospitalization? *

If you answered yes to the above question, please elaborate. Otherwise, indicate 'not applicable'.

Have you experienced any of the following in the past (check all that apply) *

Considered suicide. Have attempted suicide. Have urges to harm someone. Have urges to harm myself. No, I have not experienced any of the above.

If you checked any of the above, then please briefly elaborate. Otherwise, indicate 'not applicable'. *

Have you previously received any type of mental health services (e.g. counselling, psychiatry, etc.) *

Yes No

If you answered 'Yes' to the above , please elaborate on what would be helpful for me to know. Otherwise, please indicate 'not applicable'. *

What do you consider to be your strengths? (please list at least three) *

Emergency contact name *

Emergency number *

GP and clinic name *

Currently seeing a counsellor or psychologist? *

Yes No

The session fee is due at the time of service. The fee is $225 for 50-minute session. What is your preferred method of payment? *

Anything else you want me to know

Cancellation Policy: If you need to re-schedule or cancel your appointment, please provide a 48-hour notice. If you do not cancel within 48 hours, the full rate of your session will be charged (unless there is an unavoidable emergency). *

Yes, I understand the cancellation policy.

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Centre For Mindfulness

Dr. Kasim Al-Mashat
Centre For Mindfulness Canada (CFMC)

info@drkasimalmashat.com

604-771-0579

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Intake Form For Counselling Appointment

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