Client Form | My Quanta

Please read the Consent for Terms & Services before completing the Client Form.

Your Client Form provides us with the necessary information to legally & ethically open a file. Your Client Form will include demographic information, meeting your goals for the session, and Consent for Terms & Services. Please complete your Client Form.

Full Name *

Date of Birth (dd-mm-yyyy) *

Email Address *

Street Address *

Mailing Address

City *

Province *
Ontario
Other

Postal Code *

Telephone # (555) 555-5555 *

Alternative #

Can you tell us about the problem that seems most important to work on? How long has this been a concern? How has the problem impacted your life? *

What type of therapy session would you like? *
Individual Therapy
Couple Therapy
Family Therapy

What medium of session would you like? *
In-Person Session
Online Session

What would be the best thing that could happen in our session? *

What have you tried or done in the past that has helped you to solve problems? *

Who are the people you can talk to when you have a problem? *

Are there professionals currently involved in your care? If so, who and how are they helping you? *

What are some of your strengths and skills that help you solve problems? *

Have you read and do you fully understand the Consent & Terms of Services (found in the Services section)? *
Yes
No