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Intake Form for Counselling

Intake Form – Counselling

By completing this intake form, you are agreeing to the following confidentiality policy:

My involvement with the Stopping the Violence Program is voluntary and confidential within the limits of the law. I understand that confidential services mean that a release of any information may only happen with my written consent and that the Stopping the Violence Counsellor may not legally or ethically discuss any details of my session either personally or professionally. The following situations are exceptions: if the client is a risk to herself or another person; if the client’s life is at risk; if a child is at risk; if a court order is issued for the counsellor’s records, or; for purposes of supervision, and for case consultation within Fernie Women’s Centre staff team.

Okay to leave message? (you can check more than one)
Where would you prefer to receive counselling? (you can check more than one)
What days can you attend counselling? (you can check more than one)
Is there a counsellor you would prefer to see? (you can check more than one)
We will only call in the event of a medical emergency.


Are you feeling safe in your current relationship?
Have you recently separated from an unsafe relationship?
Have you had thoughts of suicide?
Have you attempted to end your life?

Medical and Health Information

Are you currently taking any medication(s)?
Have you ever received a mental health diagnosis?
Do you use alcohol or drugs to a point where you consider it to be a problem?
Do you have access to extended health benefits or EAP?
Are you currently attending counselling with another provider?

Counselling History and Goals

Have you ever experienced any of the following traumas?
Does oppression impact your life? e.g. racism, homophobia, ableism, sizeism
Have you seen a counsellor in the past?
Did you find it helpful?
Would you be interested in joining a group?