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General Information

First Name *

Last Name *

Date of Birth *

Age

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Pronoun

Email *

Primary Phone Number *

Is it OK to leave a message?

Yes

Secondary Phone Number

Is it OK to leave a message?

Yes

Psychological / Medical History

Is there a specific psychologist you would like to see?

Family Doctor

Family Doctor Phone Number

Is your physician aware of the issues that brought you here?

Yes

Did your physician recommend psychological treatment?

Yes

Are you currently receiving treatment for a medical condition?

Yes

Please list any health conditions/illnesses/treatments or surgeries that may be relevant to your reason for seeking out psychological treatment.

Please list any medications that you are taking.

Please briefly describe why you are seeking out psychological assistance at this time?

What do you hope to change or gain by coming to a psychologist?

Referral Information

Please let us know how you learned about our practice.

I will inform Wayfound of any changes to my intake form. The above information is true to the best of my knowledge. I understand that I am financially responsible for any balance. I also authorize Wayfound to release any information required to process my insurance claims.

I agree that all statements provided in this intake form are true and nothing has been falsified. I understand that my personal information will be held in the strictest confidence.

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Champions of Innovative Mental Health.

630, 999 - 8th Street SW
Calgary, Alberta, T2R 1J5

reception@wayfound.ca

Toll Free: 1-855-946-7792
403-850-6711

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General Information

Psychological / Medical History

Referral Information

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