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Inquiry Form For Begin Within Psychology

Fill out the form to begin the process to become a client.

Preferred Provider

Sherri A. Lees, Registered Psychologist

Nasim Switzer, CCC

First name

Email

Preferred Gender

Last name

Phone

Emergency Contact

Date of Birth

Preferred Method of Contact

Emergency Contact Phone Number

Primary Concerns for Counselling

Grief

Significant loss

Relationship issues

Parenting challenges

Physical health concerns

Mood/depression

Anxiety

Addiction

Trauma

Abuse

Anger

Self-esteem/self-image

Gender identity

Sexual orientation

Disordered eating/eating disorder

Employment/educational concerns

Are you currently under the care of a doctor?

Yes

No

Have you sought treatment from a psychologist/counsellor before?

Yes

No

Current medication/s

Yes

No

If yes, what medication/s?

Current diagnosis

Yes

No

If yes, what diagnosis?

Are any of the following a concern for you at this time?

involvement with the police or justice system

suicidal thoughts and or suicide plan

domestic violence

fear of being harmed

ongoing substance abuse

homelessness, poverty, no food

child custody issues

hallucinations or delusions

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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