FamilyTLC

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Adolescent Intake Form

  • Much of the information in this form helps us serve you better. Thank you for taking the time to fill it out. Please fill out only what you feel comfortable with. At the end of this form you will click on send button and the form is sent directly to clientservices@familytlc.ca. Please be advised that all information provided is considered confidential and will not be released without your informed, voluntary, written consent.
  • Date Format: MM slash DD slash YYYY

  • Date Format: MM slash DD slash YYYY

  • If yes, please note that we do not do third party billing. You will be responsible for paying for the session and acquiring re-imbursement from your insurance company.
  • (if other, please specify)

  • Parent Information

  • If you answered ‘yes’ to the above question, and in order to ensure your safety and security, while at Family TLC, please complete the following section.
  • Note: If you answered ‘yes’ to the above question, then you will be required to provide details to Family TLC.

  • People come to Family TLC for a variety of reasons; we wish to gain a better understanding of what your reasons are. By completing this form you are providing us with a glimpse into you and your life that will help us work with you to create a customized care plan. Please complete all applicable areas remembering that everything is private and confidential.
    We would like to learn more about the areas in your life that are causing you concern.

  • Examples: Major illness, Major injury, Significant Loss (death, job loss, divorces, move), Traumatic Experiences (abuse, crime)

  • Please include the names of the professionals you are working with:



  • Thank you for taking the time to complete this information. Your counsellor will be reviewing this with you and will be able to expand on the information if you want. We look forward to working together with you to assist you to “find your strength”.

  • If credit card
  • The cost of a one hour session range is between $140.00 from a Family TLC Partner and 250.00 from a Family TLC Associate. Our office policy is 48 hours’ notice to cancel appointments. If you provide sufficient notice you will not be charged for late cancellations. If you do not provide sufficient notice you will be billed for the missed appointment.

 

Call: 705-737-3513705-737-3513

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Call 705-737-3513

89 Dunlop St E
Unit 103
Barrie, ON, L4M 1A7

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