Personal Contact Information:Name:* Home address:* City, Province:* Postal code:* Home phone:*Cell phone:*Email:* Do you consent to email communication?* Yes No Date of Birth:* DD slash MM slash YYYY Age:*Born in (city, province):* Raised in (city, province):* Referred by:* * Please note that the security of email communication cannot be assured Emergency Contact Information:Name:* Relationship:* Home Address:* City, Province:* Postal code:* Home phone:*Cell phone:*Family Physician:Name:* Address:* Phone:*Fax:*Email (if known) *Physician information can be found at https://www.cpso.on.ca/Public-Information-Services/Find-a-DoctorMedical History:Please list your medical conditions and specify if they are past or present conditions:Medications:Please list your current medications. Please update your file when you have any medication changes.MedicationDosageFrequencyPurpose Mental Health Professionals: Please list all mental health professionals from whom you have received services past and presentName: Psychiatrist Psychologist Social Worker Psychotherapist Other Other Please add text to specifyAddress: Phone:Fax:Email: Date of last appointment: DD slash MM slash YYYY Name: Psychiatrist Psychologist Social Worker Psychotherapist Other Other: Please add text to specifyAddress: Phone:Fax:Email: Date of last appointment: DD slash MM slash YYYY Name: Psychiatrist Psychologist Social Worker Psychotherapist Other Other: Please add text to specifyAddress: Phone:Fax:Email: Date of last appointment: DD slash MM slash YYYY Employment History:*Employer:Position:Dates: At least one entry is requiredVolunteer History:Organization:Position:Dates: Relationship Status* Single, not in a relationship Common law Separated Remarried Dating, not cohabitating Married Divorced Widowed Quality of relationship: ChildrenAgeGenderQuality of Relationship Parental History:ParentStatusAgeOccupationRelationship Status Have you been the subject of a workplace investigation and/or disciplinary matter?* Yes No Have you ever been criminally charged and/or convicted?* Yes No Have you experienced suicidal thoughts, intent, means, and/or a plan?* Yes No Have you experienced homicidal thoughts, intent, means, and/or a plan?* Yes No Coverage for Psychological Services:a) Primary Extended Health Benefits Carrier (if applicable) Greenshield Manulife Blue Cross Other Plan Holder Name: Policy Number: Client Name: Policy Number: Amount of coverage per year: Amount used this year: Do you require a medical note to claim reimbursement? Yes No What is the date of your medical note (mm / dd / yyyy)?* MM slash DD slash YYYY Do you consent to direct billing for this health benefits carrier? Yes No *Note. Please provide a copy of your medical note for file records. b) Secondary Extended Health Benefits Carrier (if applicable) Greenshield Manulife Blue Cross Other Plan Holder Name: Policy Number: Client Name: Policy Number: Amount of coverage per year: Amount used this year: Do you require a medical note to claim reimbursement? Yes No What is the date of your medical note (mm / dd / yyyy)? MM slash DD slash YYYY Do you consent to direct billing for this health benefits carrier? Yes No *Note. Please provide a copy of your medical note for file records.c) Workplace Safety and Insurance Claims (if applicable)Claim number: Status of your claim: Nurse case manager: Phone number: Claim adjudicator: Phone number: Claim information (please leave this section blank):Psychological entitlement, approval for assessment and treatment, etc.Please note that billing is submitted directly to the WSIB where applicable and communication with the WSIB may be required per legislation, such as the Workplace Safety and Insurance Act.d) Other Third Party Payor (if applicable)Do you have a third party payor, other than those stated above? Yes No Company Name: Company Address: Approved by: Approval Date: MM slash DD slash YYYY Email: Phone:Are there any conditions or limitations on this approval? If so, please explain:*Do you consent to direct billing to the third party payor listed above?* Yes No Confirmation* I confirm that the above information is accurate and will update the office in writing of any changes to this information. Client Signature* Witness Signature Client Name* Witness Name Date* MM slash DD slash YYYY Date MM slash DD slash YYYY
