PRE-CONSULTATION INTAKE & CONSULTATION REQUEST FORM

This form is used solely to determine whether consultation may be appropriate.
Completion of this form does not establish a therapist–client relationship and does not guarantee consultation or services.
This practice is non-crisis and non-emergency in nature.

1. Identifying & Contact Information

Full legal name:

Preferred name (if different):

Date of birth (DD/MM/YYYY):

Current address (city, province, country):

Are you currently residing in Ontario? ☐ Yes ☐ No

Phone number:

Email address:

Current vocation, profession, or primary area of study (if applicable):

Occupation / Employer OR Student / Institution:

Emergency contact (name, relationship, phone):

2. Reason for Inquiry / Presenting Concerns

Briefly describe what brings you to seek consultation at this time:

How long have these concerns been present?

Are these concerns affecting your work, studies, relationships, or daily functioning?
☐ Yes ☐ No

If yes, please describe:

2A. Reason for Seeking Consultation With This Practice

How did you learn about my practice?

What led you to seek consultation specifically with me, as opposed to another practitioner?

Which aspects of my approach, background, or stated orientation (if any) feel relevant to your concerns at this time?

3. Therapy & Treatment History

Have you previously worked with a therapist, counsellor, psychologist, psychiatrist, or other mental health professional?
☐ Yes ☐ No

If yes, please describe below.

Approximate dates of treatment:

Type of professional(s) (e.g., social worker, psychologist, psychiatrist):

If you are comfortable sharing, please list the names and professional designations of previous therapists or mental health providers you have worked with:

Focus of treatment (if known):

Approaches or interventions used (if known):

What aspects of prior therapy were helpful?

Were there any significant challenges, ruptures, or early terminations in prior therapy that you believe are relevant to note?

4. Medications & Medical Considerations

Are you currently taking any psychiatric or neurological medications?
☐ Yes ☐ No

If yes:

Medication name(s):

Prescribing professional(s):

Purpose (e.g., mood, anxiety, sleep, attention):

Do you have any significant medical, neurological, or cognitive conditions that may be relevant to your care?
☐ Yes ☐ No

If yes, please describe:

5. Substance Use

Do you currently use alcohol or drugs in a way that you consider problematic or that others have expressed concern about?
☐ Yes ☐ No

Have you ever received treatment specifically for substance use or addiction?
☐ Yes ☐ No

Please note: This practice does not focus on the treatment of active substance use disorders. If this is a primary concern, working with a practitioner who specializes in this area is recommended.

6. Psychiatric History

Have you ever received a psychiatric diagnosis?
☐ Yes ☐ No ☐ Unsure

If yes, please list diagnoses and approximate dates:

Have you ever been hospitalized for mental health reasons?
☐ Yes ☐ No

If yes, please provide brief details:

7. Risk & Safety Screening

Have you ever experienced suicidal thoughts?
☐ Yes ☐ No

Have you ever made a suicide attempt?
☐ Yes ☐ No

Are you currently experiencing thoughts of harming yourself or others?
☐ Yes ☐ No

This practice does not provide crisis services or emergency mental health care. Individuals with active suicidality or high-risk presentations are encouraged to seek crisis-oriented or intensive services.

8. Current Symptoms & Patterns

(Please check all that apply)

☐ Anxiety
☐ Depression / low mood
☐ Trauma-related symptoms
☐ Dissociation
☐ Obsessive or ruminative thinking
☐ Relationship difficulties
☐ Grief or loss
☐ Stress or burnout
☐ Identity or life-direction concerns
☐ Other (please specify): _________________________________

Which symptoms feel most urgent at this time?

What seems to make these concerns better or worse?

9. Goals & Expectations

What are you hoping might change as a result of consultation or therapy?

What would feel helpful in the short term?

Have you worked toward these goals before? If yes, how?

10. Theoretical Orientation & Informed Disclosure

My work is depth-oriented and focuses on intra-psychic processes, unconscious patterning, and personality organization. Sessions are structured primarily around internal dynamics rather than external events. The therapeutic emphasis is on internal experience, meaning-making, and psychological structure, with limited focus on supportive or conversational counseling. Those seeking primarily supportive counseling may find a different therapeutic orientation more appropriate.

Clinical interventions may include established psychotherapy approaches, including EMDR and other evidence-informed modalities. Clinical decision-making, risk assessment, and treatment planning are grounded in established social work and psychotherapy standards of practice.

In addition to contemporary psychological frameworks, my clinical formulation of personality structure, strengths, and internal conflicts is informed in part by ancient psychological models drawn from Eastern wisdom traditions and Jewish mystical thought. These traditions are used as conceptual and symbolic frameworks for understanding inner experience and are not employed as religious instruction or belief-based counseling. They are applied with clients of diverse backgrounds, beliefs, and levels of religiosity or non-religiosity.

☐ I have read and understand the theoretical orientation of this practice.
Client initials: ____________ Date: ____________

11. Scope of Practice – Gender-Related Care

My practice does not include assessment or treatment related to gender-identity exploration, gender-affirming interventions, or transition-related care, as these areas fall outside my training and scope of practice. If these concerns are central to your reasons for seeking therapy, I encourage you to seek a practitioner with specific expertise in this area.

If concerns outside my scope arise during consultation, we will discuss appropriate next steps and referrals as needed.

☐ I have read and understand the scope limitations of this practice.
Client initials: ____________ Date: ____________

12. Additional Clinical Considerations

Are there any other psychological, psychiatric, interpersonal, behavioral, or safety-related concerns not already mentioned that you believe would be important for me to know in determining whether consultation would be appropriate?

13. Acknowledgment of Understanding

☐ I understand that completion of this form is a request for consultation only and does not establish a therapist–client relationship.

☐ I understand that submission of this form does not guarantee consultation or acceptance for services.

☐ I understand that this practice does not provide crisis or emergency mental health services.

☐ I confirm that the information provided is accurate to the best of my knowledge.

Name (printed): ______________________________________

Signature (optional): _________________________________

Date: _______________________________________________