Counselling Intake Form

Welcome to Turning Tides Life Coaching and Counselling. Please take a moment to review this confidentiality and liability waiver. If you have any questions please be sure to ask your counsellor.

First Name

Last Name

Email

Address

Code

Cell Phone

Code

Home Phone

Code

Work Phone

Preferred Method of Contact * Required

Email

Cell Phone

Home Phone

Work Phone

Is it ok to leave a voicemail?

Is it okay to send a text mesage?

Is it okay to send an email?

Date of Birth

Gender/Pronouns

Ethnicity/Race

Marital Status

Single

In a relationship

Domestic Partnership

Married

Sperated

Divorced

Widowed

Family Physician Name

Physician Phone Number

How did you hear about Turning Tides Coaching & Counselling?

Confidentiality: As a Registered Therapeutic Counsellor with the Association of Cooperative Counselling Therapists, I adhere to a strict standard of confidentiality. All the information between you and your intake counsellor or staff members will not be shared or disclosed to anyone without permission from you. I also adhere to a strict code of ethics. Exceptions (1) Federal or Provincial Court (2) criminal code violations where physical and/or sexual abuse of children are involved (3) whereby any person’s life or health is in obvious danger.

Your Signature

Date

Thank you for your submission!

Contact

Turning Tides Today Coaching & Counselling

Online Sessions offered internationally.

In-person sessions located in Vancouver, Canada.

Phone: Kotone (1) 778-321-6058

info@turningtidestoday.com

Phone: Jasleen (1) 778-828-5277

jasleen@turningtidestoday.com