Mental Health Intake Form
Please submit this completed form to: RFHT provides structured short term clinical services to those
1150 Pontiac Dr., Sarnia experiencing challenges in their life. Our focus is to provide
or 233 Cameron St. Corunna treatment that is educational & motivates the individual towards
Mental health intake worker: developing goals & skills that will support their mental & emotional
519-339-8949 or Fax: 519-339-9022 well-being. Services are offered to individuals 13+yrs & older.
Personal Information
Full Name: ____________________________________________Preferred name:______________________
Full Address:_____________________________________________________________________________
Contact #:______________________________________Can a detailed voicemail be left? Yes / No
Email:____________________________________________________Can a detailed email be left? Yes / No
Birthdate (mm/dd/yy)________________Age:_______ Gender____________
Is English your first language? Yes/ No. If no, what is your first language?____________________________
Emergency contact____________________________________Phone #:_____________________________
Family Physician:________________________________Referral source:_____________________________
Preparing for the appointment
Are you committed to attending individual therapy to work on your self-identified goals? Yes/No/Unsure
Do you prefer a specific counselor or a male/female? _____________________________________________________
Have you received counseling before? Yes / No. When and where?___________________________________________
What are some of your strengths?_____________________________________________________________________
What brings you joy? ______________________________________________________________________________
Have you experienced any recent significant life changes or stressful events?___________________________________
Todays Presenting and Current Symptoms (Check All That Apply)
Low mood Racing thoughts Trouble regulating emotions Delusions/hallucinations
Feeling hopeless Excessive worry Impulsive/risky behaviour Intrusive thoughts/ memories
Fatigue/ loss of energy Muscle aches / tension Irritability/ easily angered Feeling detached/ numb
Suicidal ideation Panic attacks Dramatic mood swings Guilt/ self blame/ regret
Inability to feel joy Poor concentration Memory impairment Heightened startle reaction
Loss of interest/ Decreased appetite/ Excessive energy/decreased need Avoiding people, places,
motivation digestive problems to sleep things
Counseling Objective
What brings you to therapy at this time?_____________________________________________________________________
____________________________________________________________________________________________________
What are your goals for therapy? __________________________________________________________________________
____________________________________________________________________________________________________
How long have you been dealing with this?__________________________________________________________________
Please share some of your current coping strategies?___________________________________________________________
_____________________________________________________________________________________________________
Turn over
Mental Health
Have you been diagnosed with a mental health disorder? Yes/No/Unsure. Please list:_________________________________
Have you ever been hospitalized for mental health? Yes/No. If so, when? __________________________________________
Current mental health medications/supplements:______________________________________________________________
Any history of mental illness in your family? Yes/No. Details:___________________________________________________
History of substance misuse in your family? Yes/No. Details:____________________________________________________
Has anyone close to you died by suicide? Yes/No. When?___________________ Relationship?________________________
Are you experiencing suicidal thoughts? Yes/No. If so, how often: Daily□ Weekly□ Monthly□
Have you engaged in self-harm behaviours? Yes/No. How often?_______________ Thoughts of harming others? Yes/No
Has your mental health impacted your ability to participate in activities of daily living? Yes/No. How so?_________________
_____________________________________________________________________________________________________
History
Who were you primarily raised by?____________________________________________ Were you adopted? Yes/No.
Did/do you have a healthy relationship with your mother? Yes/No. How about with your father? Yes/No
Did your parents separate or divorce? Yes/No. How old were you at the time? _________ Did either re-marry Yes/No.
Have you experienced a trauma that effects your life today? Yes/No.
Event:_________________________________________Symptoms:______________________________________________
How would you describe your childhood?___________________________________________________________________
Physical Health
How many times a week do you exercise? ______ Form of exercise:______________________________________________
Average hrs of sleep per night ______ Any problems with sleep?________________________________________________
Do you eat a well balanced diet? Yes/No/sometimes __________________________________________________________
Personal concerns with your: alcohol use□ substance use□ gambling behaviour□ other□_________________________
Are others concerned about your: alcohol use□ substance use□ gambling behaviour□ other□ _______________________
Please list any specific physical health problems you are currently experiencing. Eg. chronic pain. How do you cope with it:
____________________________________________________________________________________________________________________________________
Present Situation
Status (please circle): Single relationship engaged married common-law separated divorced widowed remarried
Do you have children? Yes/ No. Please List with age___________________________________________________________
Do you have custody of your children? Yes/No. Do you have a healthy relationship with your children? Yes/No
Who do you currently live with?___________________________________________________________________________
Main source of income: ____________________________________________ Is your job a source of stress? Yes/No
Have, or are you connected with any other community agencies, resources, supports? Yes/No. Please list:________________
_____________________________________________________________________________________________________
In your life, who do you turn to for support?__________________________________________________________________
Do you identify with an cultural group?__________________________ Is there anything else that you feel is important for a
counselor to know and/or would be helpful?_________________________________________________________________
Date submitted: _________________________________________________
