NEW CLIENT DETAILS FORM


Welcome to Logan Counselling Services. We look forward to providing you with caring and affordable counselling services. Please take a few minutes to fill out this form. The information will help us to better understand your situation as well as potential solutions in helping you get your life back on track. Please note - the information is confidential, for our use only, and will not be released to anyone without your written permission.

Personal Information



Emergency Contact Information

Work Information


Social / Family Information

Which best describes you? Choose all that apply.


Medical and Mental Health History / Information


Counselling Concerns

Counselling Goals

Goals are very important in counselling. They provide us with a focus and direction that will help us to help you. Please list the goal(s) that you hope to address and achieve in counselling. Please be as specific as possible.

Risk Assessment


Alcohol / Substance Use Survey

Referral Source

How did you learn about Logan Counselling Services?

Consent

Thank you for taking the time to fill out this form.

In signing below I acknowledge that the information I have provided is true and correct to the best of my knowledge at the date signed. 

Further,   I acknowledge that I have been provided with a Logan Counselling Services brochure detailing consent and rights/responsibilities of undertaking counselling,   (downlod your copy of the brochure here) I also acknowledge that it is my responsibility to read the aforementioned document and if I am unsure of any of the information I will ask for clarification from Logan Counselling Services staff.

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