Name
*
First Name
Last Name
Middle Name
Email
*
Preferred Name (If Different)
Sex
*
Gender
Pronouns
Prefix/Title
*
Date of Birth
*
Mobile Phone
*
Home Phone
(###)
###
####
Address
*
Please provide the patient's current mailing address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Health Card Number
Guardian (If Applicable)
Emergency Contact Name
*
Emergency Contact Phone
*
Emergency Contact Relationship
*
Family Doctor
*
Family Doctor Phone (If known)
*
Family Doctor Email (If known)
*
Name of Referring Professional (If Applicable)
Referring Professional's Phone (If known)
Referring Professional's Email (If known)
How did you hear about us?
*
Reason for Referral
*
Medical Diagnosis
*
Medical Treatment History
*
Mental Health Diagnosis
*
Mental Health Treatment History
*
Mental Health Family History
Medications
*
Please provide the medication names, dosage, and frequency.
Patient Symptoms
*
Please check the symptoms the patient is experiencing in the present or has experienced in the past.
Additional Patient Symptoms
*
Please check the symptoms the patient is experiencing in the present or has experienced in the past.
If the patient is experiencing any of the following and needs urgent support, please call 9-1-1, ask the patient to go to the nearest emergency department, or guide them to call local crisis and emergency service lines.
If the patient answered yes to above additional symptoms, please describe the symptoms, circumstances, or cause factors at the time and if they are experiencing any of them at present.
How would you describe the patient's level of engagement in the habits of drinking, smoking, or substance use, past or present?
*
How would you describe the patient's level of engagement in the habit of gambling, past or present?
*
How would you describe the patient's level of their daily caffeine intake, past or present?
*
How would you describe the patient's level of engagement in exercise, past or present?
*
How would you describe the patient's eating habits, past or present?
*
How would you describe the patient's level of engagement sleep and relaxation, past or present?
*
