New Clients — Psychotherapy with Ann LeBlanc

New Clients Intake Form

As a Registered Psychotherapist, I am required to have certain information about you on file as per the regulating body The College of Regulated Psychotherapists. This information is held securely in my clinical records adhering to the regulations set out in the Personal Health Information Protection Act of Ontario and the Electronic Personal Health Information Protection Act https://www.ontario.ca/laws/statute/04p03

*Please complete this form and submit through it to me through this website, 24 hours in advance of our next scheduled session.

Name

First Name

Last Name

Phone Number

Email Address

Emergency Contact (full name, relationship to you and phone number)

Full Address

Date of Birth

Medical Conditions

Formal Psychiatric Diagnosis (if any)

Family Physician Name and Phone Number

Psychiatrist Name and Phone Number (if applicable)

Current Medications

Past Medications

Occupation

Referral Source

Other Relevant Information

I consent to psychotherapy treatment with Ann LeBlanc

Yes

I have read, understand and agree to the policies described on this website

Yes

Polices

New Clients Intake Form

(647) 962-9352

400 Dupont street

TORONTO ON M5R 1V9