Intake | Johnathan Kuipers

Intake Form

The information collected in this form is legally protected and will remain confidential.

Please take your time to answer the questions to the best of your ability / comfort level

First name

Last name

Preferred name

Gender

Birthday

Phone Number

Select an Address

Emergency Contact

Relationship to emergency contact (i.e. partner, sibling, friend, etc.)

Emergency contact phone number

Sessions take place via a secure version of Zoom. Do you have any concerns with your ability to join sessions in a confidential space? Required

Yes

Regarding appointment times, are there days or times that work best with your schedule?

Please describe your reason(s) for wanting therapy.

Have you accessed therapy before? If so, for what purposes / goals?

Have you been provided any formal mental health or medical diagnoses? If so, please elaborate to the extent you feel comfortable.

Are you taking any medications or supplements? If so, please provide the name, dose, and reason for taking.

Over the past year, have you experienced or struggled with any of the following:

Is there anything else you would like me to know?

If you have health benefits and would like sessions to be billed directly to your provider (Blue Cross, Green Shield, Medavie, Telus Health, and others), please provide the appropriate details (provider, group, and member numbers) below.

Thank you for completing my intake form. I will be in touch with you shortly. Please check your junk folder if you do not see a response.