New Client Information Page

Kirsten Buhr, HakomiOT.com, 211, 5005 Elbow Drive, SW, Calgary, AB 403-903-7946

New Client Information Page: Feel free to print this, complete it and bring it your first session. Or come 10 minutes early the first time so that you have some time to fill it out before you see me. If there are any areas you are uncomfortable with, that’s OK. Go ahead and leave them aside for now.

Today’s Date: _________________

 Ms. Mr. Miss Dr .____& your Name: _______________________________

Current Address: _________________________________________________ 

City: ________________________ Postal Code : ______________________

Phone Numbers where you can be reached: ________________________________
May I leave a message at this number? : ____ (Add special instructions re: if I can ask for you at this number or leave a message. Should I leave only my first name or no name etc) _______

Email, only if you are open to me using it to contact you (Email has no guarantee of confidentiality): _________________________________________________________________________

Age: _________ Date of Birth: ___________ Gender : _________

__Single __ Married __ Partnered __Common-law __Divorced __Widowed __Prefer not to say

Occupation :________________________ Length of time at current Occupation: _______

How did you hear about my services:__________________________________________
Have you ever received Occupational Therapy, Counselling or Psychotherapy? If yes, when and for how long:_________________________________________________

Family Physician: _________________________ Psychiatrist: ________________________

Therapist: _______________________________ Emergency Contact Name: ______________

Emergency Contact Number(s): ________________________________________________

Are you currently taking any medications: Yes_ No_ If, Yes, for how long and what kinds?

How satisfied are you with your current level of:

1) Self care (eating, sleeping, grooming)notsatisfied1-2-3-4-5-6-7-8-10verysatisfied             2) Productivity   not satisfied 1-2-3-4-5-6-7-8-9-10 very satisfied
3) Leisure  not satisfied 1-2-3-4-5-6-7-8-9-10 very satisfied

 

●  Do you have a Supportive Person that you can contact if needed?:

●  Reason for today’s visit:

●  Hopes for meeting with me:

Have you received services from Alberta Health Services Mental Health programs within the last year? Yes__ No__  

If yes, from Day Hospital at Rockyview Hospital? Yes____No___
Advertisements