Client RegistrationHow did you hear about The Oak Centre?NameAgeStreet AddressCityState/ProvinceZIP / Postal CodeMobile NumberEmail AddressSkype IDOccupationRelationship Status Single Married Partnered Separated DivorcedName of Spouse/PartnerAgeHave 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:Please check any of the following behaviors that are concerning you: Porn viewing Affairs – romance/sex Over-eating Sexual massages Gambling Over-spending Internet chat rooms Alcohol Over-work Internet webcam Illegal drugs Lying or distorting truth Strip clubs Prescription drug over-use Self-centred behaviours Escorts Video games Other:Briefly describe how the checked behaviours and/or emotional states impair your ability to function effectively:Please check any of the following that you may have experienced in childhood or adulthood: Abandonment Own divorce Natural disaster Emotional neglect/abuse Abusive partner Service in war zones Physical neglect/abuse Violence in home Loss of a pet Sexual abuse Over-parented Personal criminal charges Regular criticism Victim of crime Witness to accident Rejection Parental addictions Loss of a loved one Parent’s divorce Parents fighting Loss of employment Financial hardship Multiple family moves Other:Mental Health SummaryHave you previously been diagnosed as having a mental illness? Yes NoWhen 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?Send Message
