CYC 370 Intake Form

ABC Counselling Agency Intake Form

►Client’s Basic Information

First Name: Krystal Last Name: Siddiqui

Date of Birth: 2000/05/05 Age: 22 Gender Identification/Pronouns: She/Her

YYYY MM DD

Ethnic Background: ______Pakistani_____

Primary Language: _______English____________

Is an Interpreter Required? Yes No

► (For couples counselling, please add partner’s name here)

First Name: ____________________________ Last Name: ____________________________

Date of Birth: ________/________/______ Age: _____ Gender Identification: _____________

Year Month Day

Ethnic Background: _____________________________________________________________________

Primary Language: ____________________ Is an Interpreter Required? Yes No

►Address & Contact Information

Address: Saddletowne NE

City/Town/Municipality: Calgary Postal Code: T3J

Email: krystalsiddiqui@gmail.com

Phone Numbers: Home (587) 285 7986___ Work________________ Cell____________________

Is it safe to leave detailed message at home? Yes No At Work? Yes No On email? Yes No

How far did you travel today to get to our offices? Less than 5 km 5 - 70 km More than 70 km

►Family Members & Guardian Information – describe family members and the nature of the relationship:

*Consider creating a genogram or family map (submit separately).

• Krystal is living with her parents at her home in Calgary. She describes their relationship as loving and
friendly. As well as being a great support system. She and her siblings reside in the same household,
currently she explained that her older brother is engaged to be married. Her two younger siblings have just
started getting into university.

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►Parenting Arrangements (in situations of separation/divorce): Sole Guardianship Joint Guardianship

Please describe pertinent parenting arrangements:

• Krystal describes her parents to be in a loving relationship. Both her parents are South Asians and travelled
from Pakistan to Behrain and then Canada. Krystal’s grandparents do not live in the same household as her
parents, but they visit often and she is quite fond of her grandparents.

►Emergency Contact Information

Name: Sana Address: _Saddletowne NE

Relationship: Mother Phone: (587) 917 - 5884

Is there any emergency medical information we should know about? (allergies, medical conditions)

Comment: No there are no allergies to know about.

►Current Services Accessed. Please list and describe any current supports and services that you are engaged
with:

N/A_______________________________________________________________________________

►What issues are affecting you or your family at this time (Indicate all that apply)

Anger/Irritability Issues Relationship Issues Blended or Step Family Issues Grief & Loss

Your use of Violence Child/Teen Behavior Self Esteem Depression/mood swings

Trauma Issues Parenting Issues Anxiety/ Worry/ Concerns - Anxious on a daily basis impacting her sleep

Gender Based Violence Experience of Abuse

Physical Health Issues/pregnancy/disability Sexual Behavior Issues

Adjusting to Life Transitions - Krystal is adjusting to changes with her brother’s engagement which she is
dreadful about being the only one in charge after her parents.

Stress Related Issues

Ministry of Children & Family Development Involvement Problematic Substance Use

Education/employment issues Lack of social support

Other (describe): Insomnia, eating issues (fluctuating/altering eating habits)

Are there any urgent concerns we should be aware of? (e.g. legal, suicide, or medical issues)

Yes No

If yes, please describe: _________________________________________________________

Are there any safety concerns we should be aware of? (e.g. issues relating to violence, risk taking behaviors,
threats, abuse, harm to self or others?)

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Yes No

If yes, please describe: _________________________________________________________

►Education and Employment history

Please describe information with respect to you or your family that you feel is important for us to know.

• The client is currently finishing studies at Mount Royal University. She is studying Bachelor of Business
Administration and recently finished an internship at PwC. She is currently working as a part-time at
Safeway.

►Health Information

Are there any physical issues or conditions, past or present, that we should be aware of? If you are here for child
and youth counselling, please fill out on behalf of the child

Self Child Yes No

If yes, please describe: _________________________________________________________

Have you had mental health concerns or mental health diagnoses? Yes No

If yes, please describe: Insomnia

Are you currently taking medications to address the physical or mental health issues described above?

Yes No

• If yes, please describe: She has been prescribed medications for insomnia – medicine not specified

Have you any concerns about misuse of alcohol or drug use by yourself or within your family? Yes No

If yes, please describe use:____________________________________________________________

►Physical/Somatic Concerns: Yes / No

Sleeping: Difficulties falling asleep during the night and is lethargic during the day Nightmares/sweats:

Headache: ___________________________ Stomach: ______________________________________

Heart Palpitations: ____________________ Weight: ________________________________________

Blood Pressure: _______________________ Panic Attacks: __________________________________

Shortness of Breath: ___________________ Appetite: Sometimes feels guilty of eating food she desires

Use of alcohol to relieve stress? Yes No

Frequency: __________________________________________________________________________

►Past Issues & Current Challenges

Is there any information with respect to you/ your family that you feel is important for us to know? (childhood
abuse/neglect, relationship violence, trauma, family history, significant relationships, living situation)

• Nothing she explained as such

Culture and Spiritual Beliefs

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Please describe information that you feel is important for us to know.

• Follows Islam and proudly wears her headscarf (religious symbols)

►Strengths, Abilities, & Interests

Please describe any strengths, abilities, supports, or interests that you, or your family has that could help in
addressing the issues or challenges you face:

Strengths: Ambitious

Abilities: Hardworking and persistent

Supports: Family and friends

Interests: Working at the Big 4’s (PwC, Deloitte, etc.), and travelling places with family and friends, and reading
books

►Service Delivery Preferences

Are there any needs, preferences, or assistive requirements you have regarding receiving services from the ABC
Counselling Centre? If so, please describe:

_____________________________________________________________________________

Counselor characteristics that may facilitate client progress:

• Counselor’s warm, openminded and nonjudgmental behavior facilitates the meetings. It also helps that I
understand the client’s culture, being of South Asian culture as well

Counselor characteristics that may impede client progress:

• The counselor’s inexperience and beginner knowledge may impede client progress. It was also challenging
having known the client beforehand, she was not able to be as open with the counselor, especially on
recording.

►Follow-up Permissions

The ABC Counselling Centre Agency appreciates follow-up feedback once service is completed. Please indicate if
you would be willing to participate in a brief telephone survey.

Yes No

Client Signature: ___________________ Date: September 26, 2022

Counsellor Signature: ______________________ Date: September 26, 2022

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CLIENT INFORMATION SHEET

We ask that you please read the following information and sign at the bottom.
Cancellation/No Show Policy:
In our effort to reduce the amount of time clients have to wait for service we ask that if you are unable to keep
an appointment that you inform us 24 hours in advance. This will allow us to fill your time slot with someone
from our waitlist. If you miss two appointments, without notifying us in advance, the administration staff may not
be able to re-book you. It will then be necessary to contact your counsellor for further direction. Please do not
come if you are sick, we will be pleased to rebook your appointment.

Limits of Confidentiality:
Your attendance at this office and sessions with a counsellor will be kept confidential. No material or
information will be released without your signed consent except under the following conditions:
1. The Child, Family and Community Service Act requires that we report to the Ministry for Children
and Family Development any disclosure of a child under 19 who is at risk for abuse or neglect.

2. If you share information indicating that you pose a threat to harm yourself or another person, the
counsellor will take the necessary action to ensure your safety and/or the safety of others.

3. The counsellor is bound by law to provide information in the following situations: a) Subpoenaed to
appear before a court; b) Issued a police search warrant; c) Subpoenaed by a Coroner’s Inquiry

4. Your counsellor is required to allow the review of client files for the purpose of clinical supervision and
case consultation. Your confidentiality will be protected during this review.

5. Your personal information will be entered into a database (called Counselling Trac). Information is
encrypted and stored on an offsite site webserver which is highly secure. Non-identifying elements
such as survey results may be used for agency statistical reporting.

I have read and understood the information contained in the client intake package. I have the right to
ask my counsellor any questions or have clarified any of the information that I have received from the
ABC Counselling Centre.

Client Signature: __________________ Date: September 26, 2022

Counsellor Signature: ____________________ Date: September 26, 2022

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