Julie Brundle, MA, C.Psych.Assoc.

                            Registered Psychological Associate


Client Intake Form

Welcome.  In order to make the most of our first appointment, it would be helpful for you to complete this basic intake form in advance.  Although not mandatory, you are invited to print this form and bring it to your first appointment already completed (even partially).  This information is confidential.  If you have any concerns about the relevance of any information and wish to leave it out, please feel free to do so.


Your complete Name:  _______________________________; Birthdate: _______________________________

Address:_________________________________________________________;  City:___________________________________;  Postal Code:  __________________________: Home Phone______________________;  Cell/Daytime Phone: ____________________;

Education (Grade completed, any post secondary): ____________________________________________________________________;

Current Occupation:  _________________________________________________________________________________________;

Person to alert in the event of medical emergency:  ____________________________________________________________________;

Emergency contact's relationship to you:  __________________________________;  Phone:  __________________________________;

Family Doctor:  __________________________________________________ _;  Phone:  __________________________________;

Relationship Status (circle one):    Single    Married    Partnered    Separated    Divorced    Widowed

Spouse/partner's first name:  _________________________________________________________; Age:  _____________________;  Years in relationship:  ______________________________________________;

Children (gender/age):  ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please describe any significant current or past medical problems:  ________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________Please list any medications you currently take: ________________________________________________________________________

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Have you had previous psychological care or counselling?                                      Yes                No     (circle one)

If yes, please describe: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

In your own words, what is the nature of the concern(s) you wish to address in assessment/treatment? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list any goals you might have in mind for your assessment/treatment: ___________________________________________________

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