Intake Form

Your First and Last Name (For couples please include partner's full name): *

Email Address: *

Date of Birth (MMDDYY) *

Cellphone Number *

May we leave a voicemail message on your cellphone?
YesNo

Home Phone Number *

May we leave a voicemail message on your home phone?
YesNo

Work Phone Number *

May we leave a voicemail message on your work phone?
YesNo

Your Mailing Address

Do you have a preferred pronoun?

Family Doctor:

Family Doctor Contact (can we contact them to introduce our services?):

How did you hear about Stewart & Associates? Please be specific i.e Google, Yelp, Friend, Doctor, etc.

Please list any medical issues that we need to be aware of:

Please list any medications you are taking:

Please describe any other therapy, treatment or counselling sessions you are attending:

Do you have coverage through an Extended Health Care Plan?

If Yes, Which designation does it cover? Social Worker or Counsellor (we do not have Psychologists). We must know this before being able to schedule an appointment.

Which counsellor would you like to book with?

Are you a First Nation Citizen?
YesNo

If yes, What is your status number?

For First Nations: If you or a family member attended an Indian Residential School, please provide the name of the person who attended, their relationship to you, date of birth and the name of the school.

Are you are Nisga'a Citizen?
YesNo

If yes, what is your citizen number?

For First Nations and ICBC clients, please provide your Personal Health Number:

If you are seeking counselling as a result of a car accident, please provide your ICBC Claim Number:

If you are seeking counselling via the Crime Assistance Program (CVAP), please provide your claim number:

If you are seeking counselling via the Residential Historical Abuse Program (RHAP), please provide your ID number:

Are you inquiring about a sliding scale fee? If yes, income verification is required to qualify:
YesNo

Briefly describe why you are seeking counselling.

I have read and agreed to the following cancellation policy at the bottom of this page: *
Yes