How did you hear about The Oak Centre? *Name *Age *Street Address *CityState/ProvinceZIP / Postal CodeMobile Number *Email Address *Skype ID *Occupation *Relationship Status *SingleMarriedPartneredSeparatedDivorcedName 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 viewingAffairs – romance/sex Over-eatingSexual massagesGamblingOver-spendingInternet chat roomsAlcoholOver-workInternet webcamIllegal drugsLying or distorting truthStrip clubsPrescription drug over-useSelf-centred behavioursEscortsVideo gamesOther: Briefly describe how the checked behaviours and/or emotional states impair your ability to function effectively: *Please check any of the foPlease check any of the following that you may have experienced in childhood or adulthood:llowing behaviors that are concerning you: *AbandonmentOwn divorceNatural disasterEmotional neglect/abuseAbusive partnerService in war zonesPhysical neglect/abuseViolence in homeLoss of a petSexual abuseOver-parentedPersonal criminal chargesRegular criticismVictim of crimeWitness to accidentRejectionParental addictionsLoss of a loved oneParent’s divorceParents fighting Loss of employmentFinancial hardshipMultiple family movesOther:Mental Health SummaryHave you previously been diagnosed as having a mental illness? *YesNoWhen 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?Submit Form