CTR Adult Counseling Intake Form

Your personal information shared in this intake form will be kept strictly confidential within our therapeutic team. We prioritize creating a safe and supportive environment for your healing journey, and your trust in our confidentiality measures is crucial to the therapeutic relationship.

Checkbox

Type of Referral:

Self-referral

Professional-referral for client

Professional-referral information (if applicable)

Referrer name:

First Name

Last Name

Referrer role:

Referrer phone number:

(###)

###

####

Referrer email:

Client intake information:

Initials can be used for referrals to protect client confidentiality if necessary.

Client name:

First Name

Last Name

Date of birth:

YYYY

Sex at birth:

Male

Female

Age:

Ethnicity:

Address:

Address, City, Province/State, Postal Code/ZIP Code, Country

Phone number:

Email:

Provide a brief reason for referral:

Have you sought help for this issue in the past?

How urgent is your situation?

Critical

Major

Medium

Minor

What is your role in the context of the child's life?

Parent, foster parent, adoptive parent, friend, family member, etc.

Provide the ages and a brief overview of the child(ren) in your care:

Would you say your own trauma history is involved in this issue?

If the referral is connected to a CCI case, please include the child's initials:

How did you hear about us?