Intake Forms

Filling out this intake forms helps provide essential information for your upcoming appointment. All information shared through these forms are kept secure and confidential.

Intake Forms Form

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referal

Were you referred to Veritas by anyone?

Client Varification

By signing below, I/we understand that I am/we are responsible to supply all insurance information required for therapy payment if applicable, prior to the beginning of therapy, and understand that payment is due on date of service.

Signature

Emergency Contact Information

Emergency Contact

First Name

Last Name

Emergency Email

Emergency Phone

(###)

###

####

Identifying Data

Birthdate

YYYY

Education Level

Extra Curricular Activities

Family Information

Parents/Caregivers

List the names of any parent(s) or caregiver(s) and their relation to you. Do you live with them?

Siblings

List the names, gender, and age of anyone else you live with that is under 18. What is their relation to you?

Presenting Issues

List anything specific you'd like to address with the counsellor.

Intake Forms

Discover hope & healing.