Intake Form

Please fill out the form below.

Dhammanajli Meditation Center
902 Rae Street, Regina, SK, S4T 2B4
3065808281, [email protected]

Intake Form

First Name *

Last Name *

* Indicates required field

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Gender *

M F

Date of Birth *

Personal Health Number *

Guardian Name *

First

Last

Emergency Contact *

Occupation *

Employer Name *

First

Last

Family Doctor *

First

Last

Name of referring professional *

First

Last

How did you hear about us? *

Who were you referred to? *

Presenting Problem (concerns/frequency/duration/strategies): *

History of Presenting Problem: *

Medical & Psych History *

Developmental History (childhood/social/school/work): *

Relationship History *

Family Medical & Psych History *

Drug and Alcohol Use: *

Therapy Goals and Plans *

Signature *

I certify that the above information is correct to the best of my knowledge. *

Check

I authorize the DMC clinic and its associated health professionals to collect my personal information, as documented above, for my treatment purposes only. In addition, I give my voluntary consent to the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary to benefit my treatment. I also understand that my personal information is confidential and will only be disclosed to third parties with my permission.

Click *

I agree

Cancellation policy:
I understand that this appointment time is reserved just for me. A late cancellation or missed visit leaves a hold on the therapist's day that another patient could have filled. As such, it requires 48 hours' notice for cancellations or changes to my appointment.

Click *

I agree

Signiture *

Date *

Submit

WHO WE ARE?

The Dhammanjali Meditation Center and Community Services is a non-profit organization that provides Psychospiritual-oriented counselling programs to our community and individuals seeking to promote their health and well-being, achieve their goals, and participate in our community hub.

Contact Us

902 Rae Street,
Regina, SK, S4T 2B4, Canada
Telephone: (306) 580-8281
Email: [email protected]

Privacy Policy. Copyright © 2024 Dhammanjali Meditation Center - All rights reserved

Intake Form

WHO WE ARE?

Contact Us

Subscribe Today!