Client Intake Form

Please complete this confidential intake form to help us prepare for your first session.

All information you provide is strictly confidential and protected under professional ethics codes and provincial privacy legislation. This form is transmitted securely and is used solely to support your care. If you have any questions before completing this form, please contact Leanne.

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth

Province

Street Address

City

Postal Code

Emergency Contact

Contact Name

Contact Phone

Relationship to You

Referral & Concerns

How did you hear about Leanne Perrin?

What brings you to therapy? (Primary concern)

Have you attended therapy before?

YesNo

Current Medications (if any)

Medical Conditions (if any)

EMDR Assessment

This information helps Leanne prepare for your first session. Share only what you are comfortable with at this stage.

Trauma History

Safety Assessment

Current Coping Strategies

Support System

Goals for Therapy

Consent & Agreements

Please read and acknowledge each item below. All consents are required to proceed. *

Consent to Services: I consent to receiving EMDR 2.0 therapy and related mental health services from Leanne Perrin, MSW, RSW. I understand the nature of these services and that I may withdraw consent at any time.Confidentiality: I understand that all information shared during therapy is confidential, except where disclosure is required by law (e.g., risk of harm to self or others, child abuse, or court order).Fee Agreement: I understand the fees for services and agree to pay for sessions as discussed. I understand that insurance coverage is my responsibility to verify with my provider.Cancellation Policy: I understand that a minimum of 24 hours notice is required to cancel or reschedule an appointment, and that late cancellations or no-shows may result in a cancellation fee.Records & Documentation: I understand that clinical records will be maintained in accordance with professional standards and provincial legislation, and that I may request access to my records at any time.Emergency Procedures: I understand that if I am in crisis, I should contact 911, the Canada Suicide Prevention Service (988), or my local crisis line. Therapy sessions are not a substitute for emergency services.Telehealth Consent: I consent to receiving therapy via secure video technology. I understand the benefits and limitations of telehealth, including potential technical difficulties, and agree to participate from a private, safe location.

Electronic Signature

By typing your full legal name below, you confirm that all information provided is accurate to the best of your knowledge and that you agree to the consents above.

Full Legal Name *

Date *

Having trouble with this form? Email Leanne directly