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Michael Oakes M.A., R.C.C.​

Registered Clinical Counsellor in British Columbia
​Counselling and Psychotherapy Services
MichaelOakes.ca
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    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


    If so enter the Provider Name
    BC Medical Health Number

    IDENTIFICATION
    ​

    First Middle Last
    The name you preferred to be called
    Day Month Year

    Married, Common Law, Divorced, Single, Partner: Their Name?

    Their names and ages


    EMPLOYMENT
    ​

    Employer Name if employed
    Job Description if employed
    The Name of the Employee Benefit Provider

    EDUCATION
    ​

    Degrees and Training

    ADDRESS and CONTACTS
    ​
    Include your City, Province and Postal Code
    Make sure it is correct with no typos.
    Make sure it is correct with no typos.

    Which phone number can I call, or text or leave voice messages at?
    ​​
    Include Area Code
    Include Area Code
    Name, Relationship, Phone #

    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.
    ​
    If you have one
    Where your physician works if you have one
    If you have a doctor

    MENTAL HEALTH HISTORY




    PREVIOUS COUNSELLING EXPERIENCE ​
    ​

    YOU ARE  SEEKING MY SERVICE


    Are you experiencing any of these issues below?
    ​


    If so, what are they?

    What provokes or triggers you?

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CLICK TO SUBMIT THIS FORM
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MICHAEL OAKES, M.A., R.C.C. and BCACC Member #19822
Counselling and Psychotherapy Services ~ 250-319-3660 or 
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I gratefully acknowledge and respect the lək̓ʷəŋən, and the Songhees, Esquimalt and WSÁNEĆ peoples on whose unceded territory I live, and work. I honor and respect these peoples, whose historical relationships with the land continue to this day.
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