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Background Information Form

Name
Gender

Home Address - Street Address

(only used in the event of threat to safety)

(only used in the event of threat to safety)

Where you live

(check all you think might apply)

Counselling Location
Do you have insurance coverage?

Please indicate, as this impacts which counsellor you will be assigned to.

(Please note that fees are assessed on your gross annual income. We will require you to show proof of income at your first appointment either by paystubs or annual tax return)

If you have any special requirements, please specify:

If couple or family counselling is being requested, please indicate who will join you in your counselling:

(check all you think might apply)

Presenting concern(s):
How would you score your current level of distress?
Has your current distress included thoughts or actions of suicide?
Has your current distress included thoughts or actions of self harm?

If you feel at risk right now, support is available 24/7 at:

  • Mental Health Distress Line 877.303.2642
  • Suicide Help Line 800.232.7288
  • Women's Emergency Shelter 888.346.5643
Are there risk or time factors adding to the urgency of your counselling?
If yes, what is the nature of these concerns:

(check all you think might apply) PLEASE NOTE: If your concern is legal in nature, Shalom does not provide assessments or expert witness testimony for court purposes.

Do your counselling goals include a spiritual perspective?
Do your counselling goals include a cultural perspective?
Do you feel currently you have supportive relationships in your life?
Are there health conditions that may impact your counselling goals?
Have you ever received a professional diagnosis and/or treatment for a mental health condition?
Have you or others had concerns about your use of drugs or alcohol?