Character Care
Client Intake Form

    Client Details
    Legal Guardian (If Required)
    In the Event of an Emergency:
    For Those with a Mental Health Plan or Private Health
    How Did You Hear About Our Service?
    How would you like to receive information about our services and appointments?
    Presenting Issues
    You can select up to a maximum total of 5 across Work Issues and Personal Issues
    Work Issues Selection

    Personal Issues Selection

    Impact of Issues
    You can select up to a maximum total of 5 across Work Issues and Personal Issues
    Work Impact of Presenting Issues selection
    WOS Pre-Counselling Questions
    1. For the period of the past 30 days, please total the number of hours your personal concern caused you to miss work. Include complete eight-hour days when you came in late or left early.
    2. My personal problems kept me from concentrating on my work.
    3. I look forward to going to work to start the day.
    4. So far, my life seems to be going very well.
    5. I am distressed about going to work.