Therapeutic Service Intake Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Today's date *

MM

DD

YYYY

Date of birth *

MM

DD

YYYY

What service are you interested in? *

Counselling

Restorative Mediation

Co-parenting Mediation

Do you suffer from any known mental health/psychiatric condition? *

Yes

No

Do you have a history or drug or alcohol abuse? *

Yes

No

Nationality *

Bermudian

Spouse of a Bermudian

Non-Bermudian

Marital Status *

Check all that apply

Married

Single

Separated

Divorced

Widowed

Re-Married

Employment Status

Employed - Full-Time

Employed - Part-Time

Self-Employed

Unemployed

Retired

Income *

$0 - $40,000

$41,000 - $60,000

$61,000 - $80,000

$80,000+

Referred by *

Self

Police

Medical/Doctor

Friend/Family

Other

Would you like to apply for sponsorship to cover the cost of your counselling sessions? *

Yes

No