Adult Client Intake Form

Welcome to MASC!

The information you provide is confidential, and will be helpful for your counsellor to learn more about your situation and how best to be of help to you.

If you have any questions, please ask.

    Client Details

    Insurance Information

    General Physical & Mental Health

    Substance Use

    Presenting Complaint & Goals

    Family & Relationships

    Current Symptoms
    (check all that apply)

    Crisis Information

    Anything Else

    Referral Source

    All information will be reviewed with you during your first session.