Intake Form

Client Information

First name

Last name

Birthday

Year

Month

Day

Email

Phone

Is it ok to leave a message at this number?

Yes

No

What is your preferred method of communication:

Phone Call

Text

Email

Full Address

Veterans Affairs Canada File # or Police number if applicable

WSIB case # if applicable*

Emergency Contact

First and Last name of Emergency Contact.

Phone

Relationship

Presenting Concerns

What are the main concerns that brought you to Cadence Health & Wellness Inc.

How long have these concerns been affecting you?

Less than 1 month

1-6 months

6-12 months

More than 1 year

Substance Use

Do you drink alcohol?

Yes

No

Do you use recreational drugs?

Yes

No

Have you ever felt you should cut down on your use?

Yes

No

Have you had withdrawal symptoms when cutting down or stopping?

Yes

No

Not sure

Have you ever had an overdose or needed medical care related to substance use?

Yes

No

If yes, please briefly describe what happened and when.

Have you attended treatment for addiction/substance use in the past?

Yes

No

If yes, please list program(s) and approximate year(s).

Mental Health History

Have you ever been diagnosed with a mental health condition?

Yes

No

Unsure

If yes, please list any past or current diagnoses (if known).

Have you ever been hospitalized for a psychiatric issue?

Yes

No

If yes, please give brief details (approximate dates, reasons, and name of facility).

Have you ever had thoughts of harming yourself or others?

Yes - currently

Yes - in the past

No

If yes, please share anything you feel comfortable providing (including any safety plan).

Current Supports & Medications

Do you currently have a therapist or mental health provider?

Yes

No

If yes, please provide name(s), role(s), and contact info.

Are you currently taking medication(s)?

Yes

No

If yes, please list medication name(s), dose (if known), and purpose.

Medical History

List all known allergies (medications, foods, other).

Service / Trauma Context

Have you served in the military or as a first responder?

Yes - Military

Yes - First Responder

Yes - Both

No

If yes, briefly describe your role(s) and years of service.

Are any of your current difficulties related to service, operational duties, or traumatic events?

Yes

No

Unsure

If yes or unsure, please share anything you feel is important for us to know.

Functioning & Support

Impact on work / school:

Not affected

Mildly affected

Moderately affected

Severely affected

Impact on relationship(s) / family:

Not affected

Mildly affected

Moderately affected

Severely affected

Impact on daily activities / self care:

Not affected

Mildly affected

Moderately affected

Severely affected

Who is your support system (e.g. partner, family, friends, peers, community)?

Referral Source

Brief HIPPA / Privacy Statement

"This form is hosted on a platform with PHI protection enabled and is intended for collecting health information for your care at Cadence Health & Wellness Inc. Your information is handled in accordance with applicable Canadian privacy and health information laws."

I understand that Cadence Health & Wellness Inc. will use the information I have provided to assess and support my care, and that my information will be kept confidential in accordance with applicable privacy and health information laws.

I consent to Cadence Health & Wellness Inc. contacting me using the phone number and/or email address I have provided.

Please list date and time this form was completed.

Year

Month

Day

Time

HoursMinutes

Signature

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Cadence Health & Wellness Inc.

Mental Health & Addictions Treatment Centre