Adult Mental Health Intake Form

(Adult refers to those aged 19+)

Please fill out the form to the best of your ability.

If you do not know or do not feel comfortable filling out the information below, that is alright. The more information you can give, the better it will help REACH determine a support plan for you. If this referral is for yourself, you do not need to fill out the Referee Information. If you are filling this form out for a person you are concerned for and who has given consent to seek more information or support, please fill out the Referee Information

Date*
MM slash DD slash YYYY
Inquirer Information:
(If you are filling this form on behalf of someone)
Name*
First Last
Contact Number*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Workplace*
Occupation*
Relationship to individual of concern*
How did you hear about REACH?
- Website
- Social Media
- RDF Community
- Presentation/Workshop
- Acquaintance/Co-worker/Friend
- Other
Information of Individual requiring mental health support:
Name*
First Last
Contact*

phone, email, social media
Sex / Gender Identification*
Age & Birthdate*
Occupation*
Workplace*
Insurance or Benefits*
Ethnicity*
Cultural Background*
Religion / Beliefs
Language(s)*
Annual Income Bracket*
- +100,000
- +75,000
- +50,000
- <50,000
Individuals you identify as safe or able to be a support system:*
Reason for concern or for inquiry for mental health services:
(e.g., stress, PTSD, loss, anxiety, illness, COVID-19 impacts, relational issues, etc.)
1. Primary Concern*
2. Secondary Concerns*
What are you seeking Mental Health services for specifically (if you aren’t sure, that is alright)?
What is it that you would most like support with to address in your life or aid you in moving you forward to wellbeing?
Who are you willing to receive supportive mental health services from at REACH ?
- Registered Clinical Counsellor
- School Counsellor
- Spiritual Director/Grief Care/End of Life Care
- Mental Health Navigator*
- Intern/Practicum Student Counsellor
- Other
(check all that apply, this helps us identify the most suitable Service Provider available to support you).

Mental Health Navigators include: - Family/Relational Counselling Support - Conflict and Mediation Counselling Support - Addictions Counselling Support - Grief and Loss Counselling Support - Situational Emotional Distress Support - Suicide-related Mental Health Support
Additional Comments
Please provide any additional information on whom you are willing to receive support from.
Known Diagnosis / Medical Conditions / Areas of Challenge
Mental Health
Physical Health
Other
Known support systems / Treatment or existing services in place
Medical Support
Therapy / Psychologist
Community Services
Church / Spiritual
Family Support
Other
Symptoms: recent past or currently being experienced*
- Substance use
- Suicide attempts
- Suicidal thoughts
- Obsessive thought patterns
- Chronic anxiety
- Panic attacks
- Excessive state of stress/worry
- Grief
- Anger
- Helpless/lack of support
- Abnormal fears/phobias
- Irritability/agitation
- Feeling overwhelmed
- Depressive episodes
- Prolonged feelings of sadness
- Flashbacks
- Trouble with memory/focus/motivation
- Hyper-activity
- Aggression
- Violence
- Change in sleep
- Changes in appetite
- Changes in social relationships with others (or desire to be connected)
- Challenges in understanding and engaging in day-to-day conversations
- Avoidance tactics
- Various physical ailments (headaches, aches, pains, stomachaches or feeling ‘unwell’ or too tired)
- Substance use or misuse or dependent behaviours
- Manic emotional states noticed by others/self
- Other
check all that apply
Provide any additional information on your symptoms
Is receiving mental health support part of a required plan for you?*
- Yes
- No
Risk Categories*
- Death/missing of a family member or close friend
- Close relation to someone who was seriously injured
- Exposure to suicide completed/attempted/ideation (self or other)
- Loss or sever damage of home/living situation
- Home damaged or destroyed
- Removal of children (family member) from home/family
- Removal of children (family member) from home:
- Large financial loss/Unemployment
- Witnessed domestic violence or death / injury
- Experienced domestic violence or abuse
- Exposure to substance use or addictions (self or other)
- Adjustment to a physical disability/impairment (self or other)
- Past trauma experience or exposure
- Historical or Generational Trauma (includes generational poverty and neglect)
- Other
If a category is close/similar to your experience, please check and make a note in the comment below if you feel comfortable.
Note:
Do you have health insurance coverage for counselling services? Please check with your insurance carrier if you are covered to see a Registered Clinical Counsellor (RCC).
Do you qualify for mental health services through the FNHA (First Nations Health Authority) Health Benefits program? Call Health Benefits 1-855-550-5454 to learn more about what may be covered for you.
Comments / concerns / questions
Please feel free to write any other, or extended, information here that you believe will better help explain.

Adult Mental Health Intake Form

Adult Mental Health Intake Form

Please fill out the form to the best of your ability.

Inquirer Information:

Information of Individual requiring mental health support:

Reason for concern or for inquiry for mental health services:

Known Diagnosis / Medical Conditions / Areas of Challenge

Known support systems / Treatment or existing services in place