Client Intake form for Chevon Cawood

Skip to content

Search

Kitrin

Your Growth is Our Business

Solutions
Pricing
Articles
Login

Client Details

Please complete your details below. Your information will then be loaded onto our client management and billing systems for processing.

Note :: All fields need to be completed using “none” or “N/A” where no info is applicable.

First Name *

Last Name *

Email *

Mobile Number *

Preferred Name

Preferred Pronouns

Gender Identity

Male
Female
Non-Binary
Other

Relationship Dynamic (Example: single, married, monogamous, polyamorous etc.)

Home Language

Date of Birth *

National Identification Number *

Age

Residential Address *

Residential Address Postal Code *

Residential Address Zip Code *

Postal Address

Postal Address Postal Code

Postal Address Zip Code

Occupation

Work Company Name *

Work Telephone Number *

Work Company Address *

Emergency Contact – Full Name

Emergency Contact – Email Address

Emergency Contact – Mobile Number

Relationship to Emergency Contact

Referral Source – Full Name

Referral Source – Email Address

Referral Source – Contact Number

Medical Aid Details – Medical Aid Name *

Medical Aid Details – Medical Aid Number *

Medical Aid Details – Medical Aid Plan *

Medical Aid Details – Main Member Full Name *

Medical Aid Details – Main Member ID Number *

Medical Aid Details – Dependant Full Name *

Medical Aid Details – Dependant Code *

Permission to submit diagnosis code to medical aid? *

Yes
No

Number of Adults in Home

Number of Minors in Home

Highest Educational Qualification

Unknown
Less than Grade 8
Grade 8-9
Grade 10-11
Grade 10-11 + Diploma
Grade 12
Graduate
Postgraduate
Other

Current Employment Status

Unemployed
Employed
Self-employed
Other

Current Medical Conditions or Allergies

Medication and Doses

Relevant Medical History

History of Substance Use (Past)

N/A
Over the counter
Alcohol
Cigarettes
Marijuana
Cocaine
Heroin
Other

History of Substance Use (Current)

N/A
Over the counter
Alcohol
Cigarettes
Marijuana
Cocaine
Heroin
Other

Previous History of Legal Problems

N/A
Criminal Record
Current Legal Problem
Other

Family Psychiatric History (or Suspected) – Maternal Side (include relation to patient and diagnosis)

Family Psychiatric History (or Suspected) – Paternal Side (include relation to patient and diagnosis)

I hereby declare that the information given in this intake form is true and correct to the best of my knowledge and belief. *

Yes
No

Contact Information