{"id":1465,"date":"2025-05-14T08:21:48","date_gmt":"2025-05-14T08:21:48","guid":{"rendered":"https:\/\/softwavetherapycanada.com\/arc\/?page_id=1465"},"modified":"2025-06-02T11:57:02","modified_gmt":"2025-06-02T11:57:02","slug":"psychotherapy-intake-form","status":"publish","type":"page","link":"https:\/\/softwavetherapycanada.com\/arc\/psychotherapy-intake-form\/","title":{"rendered":"Psychotherapy Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1465\" class=\"elementor elementor-1465\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-216ba9c e-flex e-con-boxed e-con e-parent\" data-id=\"216ba9c\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-25a8cc4 elementor-widget elementor-widget-heading\" data-id=\"25a8cc4\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Psychotherapy Intake<br> Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-1087c0c e-flex e-con-boxed e-con e-parent\" data-id=\"1087c0c\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-aae8723 e-flex e-con-boxed e-con e-child\" data-id=\"aae8723\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-37beb41 elementor-widget elementor-widget-heading\" data-id=\"37beb41\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">Psychotherapy <\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b612de3 elementor-widget elementor-widget-heading\" data-id=\"b612de3\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\"><span style=\"color:#4caf50;\">Intake <\/span>Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b0aaf56 contact-form elementor-widget elementor-widget-shortcode\" data-id=\"b0aaf56\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1462-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"1462\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/arc\/wp-json\/wp\/v2\/pages\/1465#wpcf7-f1462-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1462\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1462-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"container psychotherapy-form\">\n  <div class=\"row\">\n    <div class=\"col-md-6\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span>\n    <\/div>\n    <div class=\"col-md-6\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n    <\/div>\n\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"therapy-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"What has led you to seek counselling \/ therapy at this time?\" name=\"therapy-reason\"><\/textarea><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"challenge-duration\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"How long have you been having these challenges?\" value=\"\" type=\"text\" name=\"challenge-duration\" \/><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"daily-functioning\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"How do these difficulties affect you in your day-to-day functioning?\" value=\"\" type=\"text\" name=\"daily-functioning\" \/><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"coping-methods\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"How have you been coping with these difficulties until now?\" value=\"\" type=\"text\" name=\"coping-methods\" \/><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"past-therapy\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Have you received counselling \/ therapy in the past? If yes, when was this?\" value=\"\" type=\"text\" name=\"past-therapy\" \/><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"gain-goals\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"What would you like to gain from counselling \/ therapy now?\" value=\"\" type=\"text\" name=\"gain-goals\" \/><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"diagnosis\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Have you received a medical diagnosis for any physical or mental health concern? If yes, please specify below:\" name=\"diagnosis\"><\/textarea><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"appetite\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Do you experience any issues with your appetite?\" value=\"\" type=\"text\" name=\"appetite\" \/><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"stress\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Are you currently or have you recently experienced any high stress situations? (If yes, please note the reason)\" name=\"stress\"><\/textarea><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"concerns\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Do you have any concerns about being in therapy? If yes, please elaborate:\" name=\"concerns\"><\/textarea><\/span>\n    <\/div>\n\n    <div class=\"col-md-12\">\n      <h4>Medications<\/h4>\n      <p>Are you currently taking any medication(s)?<\/p>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"meds-use\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"meds-use[]\" value=\"Prescription\" \/><span class=\"wpcf7-list-item-label\">Prescription<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"meds-use[]\" value=\"Over the counter\" \/><span class=\"wpcf7-list-item-label\">Over the counter<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"meds-use[]\" value=\"Supplements\" \/><span class=\"wpcf7-list-item-label\">Supplements<\/span><\/span><\/span><\/span>\n    <\/div>\n\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"rx-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Prescription Details (Name, Dose, Purpose)\" name=\"rx-details\"><\/textarea><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"otc-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Over the Counter Details (Name, Dose, Purpose)\" name=\"otc-details\"><\/textarea><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"supplement-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Supplement Details (Name, Dose, Purpose)\" name=\"supplement-details\"><\/textarea><\/span>\n    <\/div>\n\n    <div class=\"col-md-12\">\n      <h4>Stressors<\/h4>\n      <p>Are any of the following stressors a constant in your life?<\/p>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"stressors\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stressors[]\" value=\"Smoking\" \/><span class=\"wpcf7-list-item-label\">Smoking<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"stressors[]\" value=\"Alcohol\" \/><span class=\"wpcf7-list-item-label\">Alcohol<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"stressors[]\" value=\"Coffee \/ Caffeinated Drinks\" \/><span class=\"wpcf7-list-item-label\">Coffee \/ Caffeinated Drinks<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stressors[]\" value=\"Recreational drugs\" \/><span class=\"wpcf7-list-item-label\">Recreational drugs<\/span><\/span><\/span><\/span>\n    <\/div>\n\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"smoking-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Smoking Intake - ex: packs\/day\" name=\"smoking-details\"><\/textarea><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"alcohol-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Alcohol Intake - ex: quantity\/day, type, frequency\" name=\"alcohol-details\"><\/textarea><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"caffeine-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Coffee Intake - ex: cups\/day\" name=\"caffeine-details\"><\/textarea><\/span>\n    <\/div>\n    <div class=\"col-md-12\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"drugs-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Recreational Drugs - ex: quantity\/day, substance, frequency\" name=\"drugs-details\"><\/textarea><\/span>\n    <\/div>\n\n    <div class=\"col-md-12\">\n      <h4>Agreement<\/h4>\n       I confirm that the information I have provided is accurate to the best of my knowledge and authorize the release of my medical condition to my family physician. <br><br>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"agreement\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"agreement\" value=\"Agree\" \/><span class=\"wpcf7-list-item-label\">Agree<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"agreement\" value=\"Disagree\" \/><span class=\"wpcf7-list-item-label\">Disagree<\/span><\/label><\/span><\/span><\/span>\n    <\/div>\n\n    <div class=\"btn-fomr mb-3\">\n    <input class=\"wpcf7-form-control wpcf7-submit has-spinner btn btn-default\" type=\"submit\" value=\"Submit\" \/>\n  <\/div>\n  <\/div>\n<\/div><input type='hidden' class='wpcf7-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-a490b6d e-con-full e-flex e-con e-parent\" data-id=\"a490b6d\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0eb2cfc elementor-widget elementor-widget-html\" data-id=\"0eb2cfc\" data-element_type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<iframe src=\"https:\/\/www.google.com\/maps\/embed?pb=!1m18!1m12!1m3!1d2528.2634840022547!2d-79.27715062381674!3d43.77555807109661!2m3!1f0!2f0!3f0!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x89d4d19bebda1ddd%3A0xc1c4cca0249bf38e!2s2240%20Midland%20Ave%2C%20Scarborough%2C%20ON%20M1P%204R9%2C%20Canada!5e1!3m2!1sen!2s!4v1747122853705!5m2!1sen!2s\" width=\"600\" height=\"450\" style=\"border:0;\" allowfullscreen=\"\" loading=\"lazy\" referrerpolicy=\"no-referrer-when-downgrade\"><\/iframe>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-51cb397 e-flex e-con-boxed e-con e-parent\" data-id=\"51cb397\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-9afec90 e-con-full e-flex e-con e-child\" data-id=\"9afec90\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b5dc4a3 elementor-widget elementor-widget-heading\" data-id=\"b5dc4a3\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Didn\u2019t find the answers you were looking for?<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9698f7b elementor-widget elementor-widget-heading\" data-id=\"9698f7b\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"elementor-heading-title elementor-size-default\">Just get in touch with us with your preferred method! We will try our best to help you with any and all questions.<\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-1ada86d e-con-full e-flex e-con e-child\" data-id=\"1ada86d\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3edc205 elementor-align-center btn-default wow fadeInUp elementor-widget elementor-widget-button\" data-id=\"3edc205\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"#\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Contact Us<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Psychotherapy Intake Form Psychotherapy Intake Form Didn\u2019t find the answers you were looking for? Just get in touch with us with your preferred method! We will try our best to help you with any and all questions. Contact Us<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-1465","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/pages\/1465","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/comments?post=1465"}],"version-history":[{"count":0,"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/pages\/1465\/revisions"}],"wp:attachment":[{"href":"https:\/\/softwavetherapycanada.com\/arc\/wp-json\/wp\/v2\/media?parent=1465"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}