FORM – NEW REQUEST FOR SERVICE | Markham Psychologists & Associates

I AM SEEKING SERVICE FOR:

CLIENT INFORMATION

IMPORTANT: “CLIENT” REFERS TO THE PERSON WHO WILL BE RECEIVING SERVICE.

Please add your information under "Client Information".

If someone other than you will be paying for service or booking appointments, please enter their information under "Alternate Contact".

Please add your child's information under "Client Information" and your information under "Alternate Contact"

If they do not have a phone number or email address, please enter your email and phone number as the Primary Contact Phone and Email and complete the alternate contact section.

Please add your information under "Client Information" and your partner's information under "Alternate Contact"

Please add your family member's information under "Client Information" and your information under "Alternate Contact"

Please add your information under "Client Information" and one other family member's information under "Alternate Contact"

Client First Name

Client Last Name

Client Pronoun

She / Her
He / Him
They / Them

Client Age [Self]

Adolescent 13 – 17 years
Adult 18 – 65 years
Senior 66 years +

Client Age [My Child]

Child 0 - 12 years
Adolescent 13 – 17 years
Adult 18 – 65 years

Client Age [My Partner and I]

Adult 18 - 65 years
Senior 66 years +

DAY Address PREFERRED

Client Age [My Family]

Adult 18 - 65 years
Senior 66 years +

Client Date Of Birth (D/M/Y)

Please enter Primary Contact Information.

The Primary Contact information is used by our Admins to contact you; to follow-up, book appointments and for paying for services.

Primary Contact Phone#

Primary Contact Email Address

Primary Contact Relation

Primary Contact - Would it be ok to leave a message?

Yes
No

Family Members (Optional)

Will someone other than the client or individual completing this form be paying for service, or booking appointments.

Yes
No

Would you like to enter an Alternate Contact?

Yes
No

Please enter your partner's information below.

ALTERNATE CONTACT INFORMATION

Alternate Contact First Name

Alternate Contact Last Name

Alternate Contact Email Address

Alternate Contact Phone#

Alternate Contact - Would it be ok to leave a message?

Yes
No

Alternate Contact - Relationship to Client

Parent
Spouse / Partner
Family Member
Friend

SERVICE REQUESTED

SERVICE SOUGHT

Individual Treatment
Couples Treatment
Family Treatment
Diagnostic Clarification (no formal testing or report)
Full Assessment (formal testing and report)

PRESENTING CONCERNS

Select Primary and Secondary Concerns

Primary Concern

Primary Concern - If Other Please Specify

Secondary Concern

Secondary Concern - If Other Please Specify

HOW DID YOU HEAR ABOUT US?

How Did You Hear About Us - If Other Please specify

If Professional or Hospital / Agency has referred.
Please provide the following information:

Referral: Full Name

Referral: Profession

Referral: Email or Mailing Address

Refferal: Phone #

SERVICE LOCATION PREFERENCE

In Office
Secure Video
Telephone

IF IN OFFICE NOT AVAILABLE IN NEXT 3 WEEKS WOULD YOU CONSIDER

Only Interested in "In-Office"
Would consider secure video or phone

DAY / TIME PREFERENCE

No Preference
Weekday Daytime (9am to 5pm)
Weekday Evening (after 5pm)
Weekend (Anytime)

IF WEEKDAY EVENING OR WEEKEND NOT AVAILABLE IN NEXT 3 WEEKS WOULD YOU CONSIDER

WEEKDAY DAYTIME

Yes
No

GENDER PREFERENCE

Female
Male
No Preference

URGENCY OF SERVICE

1 week
2 weeks
Longer

PREFERRED CONTACT METHOD

Phone
Email

BEST TIME TO CALL (Select all that apply)

Weekday daytime
Weekday evening
Weekend

Refered To

Were your referred to, or wanting to book an appointment with, a specific practitioner?

If so, please select their name from the list below. If you are deciding between a few practitioners, or do not know who you want to book an appointment with, please select “not sure, need assistance” below.

Our admin staff will assist you in choosing a practitioner who is the best match to your needs when they contact you.

Practitioner

Additional Comments