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Start your path to well-being by completing our Therapy Intake Forms. These forms allow us to gather information to ensure our services will meet your mental health needs. Therapy Intake Form I'm seeking services for: Myself (Please note that our clinicians only work with individuals under 30 unless you are seeking parenting support). My child Client's first name Parent's first name if client is a minor (under 18) Client's age Gender Phone number Email City of residence How did you hear about us? Service provider (e.g., pediatrician, general practitioner, psychologist, counsellor) BC Psychological Association Google or another search engine Family/Friend Other (please specify) Do you have extended health benefits coverage? Yes No Unsure Do you have coverage from any specific funding? Yes, from FNHA Yes, from Autism Funding Other (please specify) No What type of therapy service are you looking for? In person Virtual Either virtual or in person Do you have a preference for a specific clinician? Dr. Juliana Negreiros (R. Psych.) Dr. Kevin Noble (R. Psych.) Kelly Archer (RCC) Doctoral student or therapist working under either Dr. Juliana or Dr. Noble's supervision No preference. I will see whoever is accepting new clients so I can book an appointment sooner Reasons for seeking therapy services What problems have been concerning you? Please provide a brief description if applicable. Symptoms of anxiety (e.g., excessive worries about little things, perfectionism, social anxiety, phobias, physical complaints) Symptoms of obsessive-compulsive disorder [OCD] (e.g., intrusive thoughts/images/urgers, mental or physical compulsions, avoidant behaviour) Symptoms of body-focused repetitive behaviours [BFRB] (e.g.,hair pulling, skin picking, nail biting) Symptoms of ADHD (e.g., regulating attention, impulsive/hyperactive behaviour) Difficulty with peer interactions (e.g., friendships, bullying) Difficulty with family relationships (e.g., parent-child, sibling) Parenting challenges (e.g., setting consistent boundaries for their child, frequent conflicts, power struggles) Trouble at school/college/work (e.g., falling behind in schoolwork, getting into trouble with teachers, having conflicts with coworkers) Mood is low (e.g., irritable, low energy, sad, isolates self, feels hopeless) Impulsive or non-compliant behaviour (e.g., acting without thinking, refusing to follow rules or instructions, not obeying authority figures) Often breaking the rules or getting in trouble (e.g., skipping school or getting into fights) Risky or dangerous behaviours (e.g. self-harm, talking about suicide, threatening others with violence) Trauma (e.g., physical or sexual abuse, witnessing violence, or being involved in a serious accident) May be abusing substances (e.g., tobacco, alcohol, drugs) Body image or eating challenges (e.g., being overly concerned about weight or appearance, constantly dieting) Symptoms related to autism (e.g., difficulty with social communication, rigid behaviour, need for predictability, sensory sensitivities) Gender identity questions (e.g., having uncertainties or concerns about one's gender identity) Have there been any recent stressors that could be contributing to the client's difficulties? Please indicate below: 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: Submit 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 Want to know how we protect your data? Click here to learn more.