Client Admission Form

Please take a moment to fill out the form below

To assist in your intake process, we require our patients to complete this form. We collect information that provides a deeper insight into your history and helps us tailor the goals of your program for your best possible results. Once you submit this form, we will contact you with information for the next step in treatment.

Client (Patient) Information:
Legal First Name*
Legal Last Name*
Preferred Name
Date of Birth*
Gender*
- Male
- Other
- Prefer not to say
Email Address*
Employment Status
Occupation
Marital Status
Cell Phone Number
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Hidden
Home Phone Number
Hidden
Other Phone Number
Hidden
Age
Provincial Health Care Number*
Extended Health Care Number
Extended Health Carrier
Group Plan No. (Back of Card)
Emergency Contact Name
Emergency Contact Phone Number
Emergency Contact Relationship
Referring Professional

(if applicable)
Were you referred to Sunshine Coast Health Centre by one of the following professionals?
- Therapist
- Psychologist
- Psychiatrist
- Interventionist
- Other
If Other, Please Specify
Name of Professional(s)
Date Available for Medical Information Phone Call
Time

: Hours

Minutes

AM/PM
Please Provide an Additional Available Date
Time

: Hours

Minutes

AM/PM
Phone
This field is for validation purposes and should be left unchanged.

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Client Admission Form

Please take a moment to fill out the form below

Client Admission Form

Client (Patient) Information:

Referring Professional