Adult Mental Health Intake Form

(Adult refers to those aged 19+)

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

The more information you can fill out on this form, the more helpful is is for us at REACH to determine a support plan for you. If you do not know, or do not feel comfortable filling out the information, that is alright; please put n/a in any box you do not want to fill or that you do not have the information for.

"*" indicates required fields

Step 1 of 6

16%

Date*

MM slash DD slash YYYY

Inquirer Information:

Your Name*

First Last

Your Contact Number*

Email*

How did you hear about REACH?*

Website

Social Media

RDF Community

Presentation/Workshop

Acquaintance/Co-worker/Friend

Other

Are you filling out this form for yourself or someone else?*

Myself

Someone else

Relationship to individual of concern*

Their Name*

First Last

Their Contact*

phone, email, social media

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Information for mental health support:

Sex / Gender Identification*

Age & Birthdate*

Occupation*

Workplace*

This field is hidden when viewing the form

Occupation

This field is hidden when viewing the form

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

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.