INTAKE Michael Oakes Registered Clinical Counsellor in B.C. Canada

MICHAEL OAKES, M.A., R.C.C. and BCACC Member #19822, Counselling and Psychotherapy Services
All communication between us is strictly confidential. Please fill out this CLIENT INTAKE FORM. Some fields are mandatory (marked with a Red *). You must fill those out as best you can otherwise the form will not be sent.

Client Intake Information

How did you find my service? *

Referral Internet Search Other

If by referral, who or what agency referred me? *

You are Seeking *

Individual Therapy Couples Therapy

Do you have 3rd Party Insurance Coverage? *

PHN *

Full Name *

Preferred Name *

Significant Adult Relationship, Marital Status *

Who resides with you in your household? (name and relationship) *

Do you have children? *

Yes No

Do they live with you? *

Yes No Occaisionally

If you have children what are their names and ages? *

Are you employed? *

Full Time Part Time Unemployed Retired

Employer *

Occupation *

If employed, what do you enjoy and what is stressful about your job *

Do you have Employee Benefits? *

Yes No

If Yes What is the Employee Benefit Source Name *

Are you in School? *

Yes No

If in school, where and for what? *

Your Educational Level *

ADDRESS and CONTACTS

Your Home Address *

Your Email Address *

Alternate Email Address if you have one *

Which phone number can I call, or text or leave voice messages at?

MOBILE Phone # *

Or Alternate Phone # *

If I need to contact you, check your preferences: *

Voicemail Text Message Email

In case of an emergency, who should I contact? *

MEDICAL HISTORY
NOTE: I may need to confer with your Doctor but I will discuss this with you and get your permission before doing so.

Your Doctor's Name *

Clinic Name *

Doctor's Phone Number *

Are you taking any prescribed medications? If so, what are they? *

Have you ever been hospitalized? If so, when and what for? *

MENTAL HEALTH HISTORY

Have you had a formal medical or mental diagnosis? If so, what for and when? *

List any mental health services you have used in the past and when. *

Have you had involvement with the criminal justice system? If so, what for and when? *

Have you had any history of substance abuse? If so what and when. *

Have you had any history of attempted suicide? *

Yes No

Have you had any history of violence? *

Yes No

Have you had any history of emotional, physical, sexual abuse or trauma? *

Yes No

Is there any other history that relates to your concerns? *

Have any of your family members had mental health or substance use histories. If so who, what and when? *

PREVIOUS COUNSELLING EXPERIENCE

Have you had any therapeutic counselling experience before? *

Yes No

If so, with whom, when and for how long? *

What issues did you work on? *

What was helpful with this experience? *

What was not helpful with this experience? *

What were the results from this experience? *

YOU ARE SEEKING MY SERVICE

What type of session do you prefer? *

Phone session Video session

What is prompting you to seek my service? *

What are the primary issues, problems and challenges that you are struggling with and when did they start? *

What do you hope to see as a result of seeking therapy with me? ie: Your Therapeutic Goals *

Are you experiencing any of these issues below?

How many caffeinated beverages do you drink in a day? *

How many alcoholic beverages do you drink in a week? *

Do you use any other drugs on a regular basis? Specify what, how much, how often and since when? *

Are you experiencing any life transition issues? *

What was it like for you growing up? (Family Structure, Siblings) *

What was your parents’ or guardians’ approach to discipline? *

What are some of your biggest challenges, difficulties and areas of struggle? *

What makes you frustrated, angry, hurt or uncomfortable? *

What are some of your greatest accomplishments, successes and sources of pride? *

What brings you feelings of happiness, calm, peace and enjoyment? *

What might be helpful to you in counselling? *

All communication between us is strictly confidential.

Michael Oakes M.A., R.C.C.​

​Client Intake Information

Michael Oakes M.A., R.C.C.

Client Intake Information