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'.

Please select ALL that apply.

Mood swings Alcohol/substance abuse Hallucinations Body image issues Eating issues Sleeping difficulties (e.g., under/oversleeping) Withdrawing socially Lowered mood Anxiety Panic attacks Trauma and/or symptoms of PTSD None of the above apply

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 $235 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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Name *

First

Last

Email *

Phone

What is your date of birth? *

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

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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 optimistic

Do you take prescription medication? *

Please list medication(s):

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

Please describe the life changes briefly:

Please select ALL that apply: *

Mood swings
Alcohol/substance abuse
Hallucinations
Body image issues
Eating issues
Sleeping difficulties (e.g., under/oversleeping)
Withdrawing socially
Lowered mood
Anxiety Panic attacks
Trauma and/or symptoms of PTSD
None of the above apply

Any previous overnight hospitalization? *

Yes, for medical/surgical reason(s) only
Yes, for psychological reason(s) only
Yes, for both medical/surgical AND psychological reasons
None

Please elaborate on the overnight hospitalization(s):

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

Please briefly elaborate:

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

Please elaborate on what would be helpful for me to know regarding prior mental health services:

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

Emergency contact name *

First

Last

Emergency phone number *

GP and clinic name *

Are you currently seeing a counsellor or psychologist? *

The session fee is due at the time of service. The fee is $235 for 50-minute session. What is your preferred method of payment? *

Interact e-Transfer
Cheque
Credit Card (NOTE: there is an extra 8% processing fee for credit cards payments)

Anything else you want me to know

Yes, I understand the cancellation policy.

Free E-Newsletter signup!

Yes, I want to receive the latest tips, videos, and upcoming program info!

You can unsubscribe at any time.

Intake Form For Counselling Appointment

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

Free E-Newsletter Signup!

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Intake Form For Counselling Appointment

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

​​Free E-Newsletter Signup!

Newsletter Subscribe

Subscribe to the newsletter

Subscribe to the newsletter

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

Free E-Newsletter Signup!