Single Session Counselling Clinic Screener

I/We understand and consent to the above counselling and service conditions.

Client Name(s)

Signature – consent provided

Demographic Information

First Name

Last Name

Date of Birth

Gender Identity

Pronouns

E-mail

Do we have your permission to send you an e-mail?YesNo

Home Phone

Work Phone

Cell Phone

Can we leave a message at the phone numbers listed?YesNo

Address

City

Postal Code

Emergency Contact

Languages spoken at home

Who else lives in your household? (such as children, dependents, roommates, or other family members)

First Name

Last Name

Date of Birth

Relationship

First Name

Last Name

Date of Birth

Relationship

First Name

Last Name

Date of Birth

Relationship

Have you been to walk-in Counselling Clinic before?YesNo

Do you have an EAP (Employee Assistance Program) through your employer?YesNo

Employer:

What would you like to talk to a counsellor about today?

Risk Assessment Summary

Have you ever been affected by any of the following?Addictions (alcohol, drugs, gambling)Intimate partner or family violenceSexual assaultDevelopmental disabilitiesFinancial problemsWork or interpersonal conflictRisk to self or other