Sacred Evolutions
Counselling Intake Form

If you are new client please fill out this intake form prior to your first appointment with Leanne. We will review together.

Counselling Intake form

Please fill out the following form.

First name

Last name

Date of birth

Year

Month

Day

Email

Cell Phone

OK to Leave Text and Voice Messages?

No

Yes

Alternate Phone (optional)

OK to Leave Text and Voice Messages?

No

Yes

Address

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Location

Relationship to you

Reason you are seeking counselling today

Have you had any previous therapy/ counselling

No

Yes

When and Number of Sessions

Name and phone # of previous counselor

Type of therapy received

Reason you stopped seeing them

Do you you have any Mental Health Diagnoses?

No

Yes

Name and Date of Diagnoses

Have you ever considered suicide?

No

Yes

When was that? Is it ongoing?

Have you ever or are you currently using any substances?

No

Yes

Select Type of substance

Alcohol

Tobacco/ Vape

CBD/THC

Other Recreational Substances

List type of substance, frequency and date of last use

Are you suffering from any medical conditions, illness or injury?

No

Yes

If yes please describe

Are you taking any Medications?

No

Yes

List Medication Name, Dosage, Frequency and reason for taking

Initials

I certify that the information provided on this form is true and correct to the best of my ability, and acknowledge that typing my initials in the signature box below acts as my signature.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

2) Submit Payment By E-transfer

Registration is confirmed upon payment

Early Bird Pricing- By Feb 15, 2025
$725 CAD

50% deposit or $362.50 CAD to register before Feb 15, 2025

The remaining 50% or $362.50 CAD to be paid in full by March15, 2025.

Standard Pricing
$777 CAD

50% deposit or $388.50 CAD received after Feb 15, 2025

The remaining 50% or $388.50 CAD due by April 15, 2025

All payments can be made by e-transfer to leanne@sacredevolutions.ca (Preferred Method)

You may also pay by credit card via Paypal. Email me and I will send you a paypal invoice.

Paypal is subject to Paypal fee: 2.9% + 30c per transaction

* Concerned about finances? I'm happy to chat. Alternate payment schedules can be made. Please contact Leanne to inquire.

3) Book Your Room (Optional)

Once the registration form and e-transfer payment is received you will be emailed a confirmation of registration and a room booking link for the Naramata Center.

Book your accommodations for the Naramata Center by March 1, 2025 through the booking link.

See information about the accommodations on the Workshops Page.

Don't Miss My Responses!

Sometimes my email responses will go to your Junk Mail. Please add my email address:

Leanne@sacredevolutions.ca as a contact and be sure to check your junk mail if you don't see a response from me within 24 hours.