Background Information Form – Frontline Resilience

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:*

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-Doctor

Medical 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.

Medication	Dosage	Frequency	Purpose

Mental Health Professionals:

Please list all mental health professionals from whom you have received services past and present

Name:

Psychiatrist
Psychologist
Social Worker
Psychotherapist
Other

Other

Please add text to specify

Address:

Phone:

Fax:

Email:

Date of last appointment:

Name:

Psychiatrist
Psychologist
Social Worker
Psychotherapist
Other

Other:

Please add text to specify

Address:

Phone:

Fax:

Email:

Date of last appointment:

Name:

Psychiatrist
Psychologist
Social Worker
Psychotherapist
Other

Other:

Please add text to specify

Address:

Phone:

Fax:

Email:

Date of last appointment:

Employment History:*

Employer:	Position:	Dates:

At least one entry is required

Volunteer History:

Organization:	Position:	Dates:

Relationship Status*

Single, not in a relationship
Common law
Separated
Remarried
Dating, not cohabitating
Married
Divorced
Widowed

Quality of relationship:

Children

Age	Gender	Quality of Relationship

Parental History:

Parent	Status	Age	Occupation	Relationship 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)?*

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)?

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:

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*

Date