Oakridge Counselling & Wellness Centre Oakridge Counselling
Client Intake Form 		Elizabeth A. Lacey Elizabeth A.
Lacey
MSW RSW

Relationship
Specialist
 Relationship Breakdown

CoupleSign up
for my Newsletter:
"Relationship Reboot"
and...
Get your FREE GUIDE
"Build a Lasting,
Happy Marriage"
IMMEDIATELY

RELATIONSHIP REBOOT
Subscribe Unsubscribe
First Name:
Last Name:
Email:
 

Marriage Make-Over



Home

Contact Elizabeth

About Elizabeth Lacey

Fees & Appointment Times

Forms

Resources

Links & Phone Numbers

Site Search

Stress Reduction

Yoga Classes

First Name:

  


Last Name:

  


Phone Number:

  


Email Address:

  


Marital Status:

  


Family Doctor:

  


What is the issue(s) you are seeking counselling to address?


How does the issue affect you on a day to day basis?


How long has this been an issue?


What else have you tried to remedy the situation?


Do you have any medical conditions that you take medication for?


If so, what is the condition and what medication(s) are you
currently taking?


Have you been to counselling before?


What do you hope to get from counselling?


Please list any other information that you think is relevant.

Thank you for taking the time to complete this
Client Intake Form.
___________


I must conquer my loneliness
alone.

I must be happy with myself
or I have
nothing
to offer you.

Two halves have
little choice
but to
join;
and yes,
they do
make a
whole.

But two
wholes
when coincide…
that is
beauty.

That is
love.

Peter McWilliams (1970)

There is Hope for Your Marriage

Credit Cards Accepted
Valid HTML 4.01 Transitional


759 Hyde Park Road, Suite 254, London, ON N6H 3S2 ::: Phone: 519.471.4540 Fax: 519.657.2764 (MAP)
Contact Elizabeth by Confidential Email

Website developed and maintained by LaceyCo Consulting.
Copyright © 2005-2009 Oakridge Counselling. All rights reserved.
 Lotus Flower