Why are you seeking therapy services? Please check the box for any symptoms that apply and provide a brief description if needed.

Internalizing Behaviours:

Anxiety Symptoms: May include concerns such as worries about small details, striving for perfection, fears related to social situations, specific phobias, and physical symptoms like stomachaches.

OCD Symptoms: Could involve unwanted recurring thoughts, repetitive behaviours, or avoiding certain places or situations.

Body-focused Repetitive Behaviours (BFRB): Might involve hair pulling, skin picking, nail biting, or other similar repetitive behaviours.

Low Mood: Possible symptoms include feeling irritable, lacking energy, appearing sad, isolating from others, and feeling hopeless.

Trauma Related: Potential experiences of physical or sexual abuse, witnessing violence, or being involved in a serious accident.

Externalizing Behaviours:

ADHD Symptoms: Might present challenges in focusing, impulsive actions, or overly active behaviour.

Impulsive or Non-compliant Behaviour: Could include acting without thinking and resisting following directions.

Defiant Behaviour: Might be characterized by refusing to listen to authority figures and frequently breaking rules.

Rule-breaking Behaviour: Could include truancy and involvement in fights.

Risky Behaviours: Might include self-harm, discussions of suicide, or threatening violence.

Developmental Concerns:

Autism Spectrum Symptoms: Possible difficulties with social skills, a preference for routine, and sensory sensitivities.

Developmental Delays: May involve not meeting age-appropriate developmental milestones.

Other Specific Concerns:

Social Challenges: Issues could involve making or keeping friends and facing bullying.

Family Relationship Difficulties: Might include struggles in relationships with family members such as parents or siblings.

Parenting Challenges: Could involve difficulties in setting consistent rules, frequent arguments, and power struggles.

School/Work Troubles: Challenges may include falling behind academically, issues with teachers or peers, and conflicts at work.

Substance Abuse: Might involve the use of tobacco, alcohol, or drugs.

Body Image or Eating Issues: Concerns might include being overly concerned about weight or constantly dieting.

Sleeping Problems: Possible troubles include difficulty falling or staying asleep and night-time worries.

Gender Identity Concerns: May involve questions or uncertainties about one’s gender identity.

Have your child (or you if the client) ever:

Endorsed suicidal thoughts?

Engaged in self-harming behaviour?

Been taken to the ER or been hospitalized due to mental health concerns?

None of the above

Is there any other information that you would like to share that may help us better support the client? Please indicate below:

Thanks for submitting!

Thank you for completing this form. We will review your information and contact you as soon as possible. Please note that due to the high demand for services, there may be a delay in our response. Service availability depends on clinician availability and client needs. Should you have any questions in the meantime, please don’t hesitate to contact us at contact@beaconpsychology.ca.

Warm regards,

Beacon Psychology Team

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Therapy Intake Form

Welcome to Our Clinic!

As part of our intake process, we ask you to help us understand the reasons you are seeking our services. Please complete the following fields:

Why are you seeking therapy services? Please check the box for any symptoms that apply and provide a brief description if needed.

Therapy Intake Form

Welcome to Our Clinic! As part of our intake process, we ask you to help us understand the reasons you are seeking our services. Please complete the following fields:

Why are you seeking therapy services? Please check the box for any symptoms that apply and provide a brief description if needed.

Welcome to Our Clinic!

As part of our intake process, we ask you to help us understand the reasons you are seeking our services. Please complete the following fields: