Adolescent Intake FormMuch 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 email@example.com. Please be advised that all information provided is considered confidential and will not be released without your informed, voluntary, written consent.Today's Date Date Format: MM slash DD slash YYYY Your Name* First Last Your Date of Birth* Date Format: MM slash DD slash YYYY Your Gender*-Gender FluidFemaleMaleTransgenderYour Email* Address Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code PhoneEmergency Contact Name* First Last Emergency Contact Phone Number*Emergency Relationship to youDo you have insurance that covers counselling?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.YesNoI don't knowIf yes please specify type of professional you have coverage for Master Social Work (MSW) Registered Social Worker (RSW) Psychotherpaist Other(if other, please specify)Parent InformationCustodial Parent A First Last Emergency ContactCustodial Parent A Email Custodial Parent A PhoneCustodial Parent B First Last Emergency ContactCustodial Parent B Email Custodial Parent B PhoneRelationship StatusSingleDivorcedMarriedWidowedSeparatedCommon LawCustody Arrangements if Divorced/SeparatedSole CustodyShared CustodyFosterKinshipNot establishedJointprimary residence withWould you like your parent(s) to be involved in counselling?YesNoAre any of the following a concern for you? Safety/Security ViolenceIf 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.Do you have a restraining order and/or peace bond in place? If yes, with whom?Note: If you answered ‘yes’ to the above question, then you will be required to provide details to Family TLC.Please describe why Safety/Security and/or Violence is a concern.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. Describe what brings you in to Family TLC?Please Check off any behaviours or symptoms you may be struggling with or experiencing Anxiety/Worry Sadness Change in Appetite Agitation Life Pressure Stress Sleep Problems Pornography Low Self-esteem Making Decisions Trouble concentrating Sexual Identity Aggression/Fights Peer/Sibling Conflict Crying Easily Self-harm Behaviour Bullying Tired all the time Sexual Assault Eating Disorder Thoughts of Death/Suicide Irrational and Excessive Fear Mood Swings Hallucinations Delusions Loss of interest in work or hobbies Problems in relationship Sex Feeling Apprehensive and Tense Difficulty Managing Daily Tasks Feeling Distress Related to these TasksPlease Check off any concerns around your Identity Sexuality Gender Beliefs Self Esteem OtherPlease list any other difficulties or struggles you want us to knowHave you had any traumatic upsetting experiences in your life? Please list and describe.Examples: Major illness, Major injury, Significant Loss (death, job loss, divorces, move), Traumatic Experiences (abuse, crime)Please list any current health concernsAre you currently on any medication?YesNoIf yes please specifyHave you experienced any of the following medical conditions? Allergies Chronic Pain Dizziness/Fainting Surgery Asthma Seizures Vision Problems Abortion Headaches OtherHave you used drugs/alcohol or prescription medication in the past 6 months and been concerned about the impact?Who is supportive in your life? Friends Teachers Counselor Youth Group Mentor OtherPlease describe any relationships in your life right now that you find supportivePlease include the names of the professionals you are working with:Medical Professional(s):Health & Wellness Professional(s):Lawyer:Community Organization/Educational Staff:Financial Advisor:Spiritual Advisor:Other:Have you ever received counseling before?YesNoWhat are some goals you would like to accomplish in the next 5 years?How did you find out about Family TLC? Website Brochure Word of Mouth Referred Directory OtherReferred by:Anything else you would like to share with us?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”.Your parents are welcome to pay for your counselling by providing their credit card information in advance or by giving your therapist cash or cheque made out to Family TLC.Cash or ChequeDebitCreditEtransfterIf credit cardNameCredit Card #Expiry DateSecurity 3 digit code on backThe 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.By checking this box I release the above information to Family TLC for administration purposes. All information provided is considered confidential and will not be released without your informed, voluntary, written consent.* Yes, I agree.