Client Registration | The Oak Centre

How did you hear about The Oak Centre? *

Name *

Age *

Street Address *

City

State/Province

ZIP / Postal Code

Mobile Number *

Email Address *

Skype ID *

Occupation *

Name of Spouse/Partner

Age

Have you ever been in counselling before? If so, for how long and what were the problems or issues? *

Describe your currents problem or issue that you would like to overcome or resolve: *

Briefly describe how the checked behaviours and/or emotional states impair your ability to function effectively: *

Mental Health Summary

Have you previously been diagnosed as having a mental illness? *YesNo

When were you diagnosed?

What was the diagnosis?

Are you currently taking medication for your diagnosed mental illness? If so, what is the medication, frequency and dosage?

Are you currently taking any other medications? If so, what is the medication, frequency and dosage?