Background Information Form

You may complete and submit the following form online, or, download a copy and print and submit at your convenience:

Please Note: Our Background Information form can be filled online by selecting Option 1. below. If you prefer to complete the form manually, please download the form at option 2 below.

Your counsellor is usually assigned within 3 business days of receiving your form. If you have not received a call to set up your first appointment by this time, please email ([email protected]) or call us at (403) 342-0339 to confirm your appointment status.

Option 1. Complete the online Background Information Form below, or;

Option 2. Download the Shalom Background Information form then drop off, mail, scan, email, or fax your completed form to [email protected] (fax 403-314-1798). Our mailing address is

Shalom Counselling Centre
5515 27 Ave,
Red Deer, AB T4P 0E5

Parents of Minors, please download and return the Parental Consent Form

Disclaimer:
Confidentiality and privacy are held to a high standard at Shalom Counselling Centre, however if you choose to complete and submit forms to us online, your privacy cannot be guaranteed for any communication taking place via the internet.

For more information about Shalom, call us at 403-342-0339 or email [email protected].

Name
Gender
Home Address - Street Address
Requesting a specific Counsellor?
Counselling Location
Benefit Plans

If you are seeking insurance coverage from a private plan, check if they have specific requirements. Such requirements may be that you only see a therapist of their choosing, or only a therapist with very specific designations. If you have any of these specific requirements, please specify:

Are you a returning client?
Does the counsellor have permission to review files of your previous sessions.

Information For Your Counsellor At Shalom

Please describe your concerns

Do your counselling goals focus on spiritual concerns?
Supportive Relationships

Who do you turn to for help and encouragement now:

Please list by year any deaths, prenatal losses, major upsets or significant changes that have impacted you or your immediate family.

Do your counselling goals concern a legal action?

Employment

Any job changes this year?

Relationship History

Relationship
Partner's Name

(years/months)

(years)

Have you ever separated?
Have you or your partner been previously in other married/common law relationships?
If yes, please check applicable status

Family History

Family of Origin Story

In the home you grew up in, was there:

Medical Information

Are there any health conditions that may impact your counselling concerns?
Have you ever received a diagnosis and/or treatment for your mental health condition?
Have you noticed recent changes in any or all of the following?

If you have experienced weight loss/gain please also explain the number of pounds over the number of weeks.

Are you presently taking any medication?

Please provide names, dosage, length of use, and purpose of each medication you're taking.

Has anyone expressed concern for your alcohol or drug use?
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