Stacy Finch, RCC

Life Coach and British Columbia Registered Clinical Counsellor #20192
www.stacyfinch.com
stacy@stacyfinch.com

RM_Stats

Email^*

First Name

Last Name

Gender

Address

City

State or Province

Zip or Postal Code

Country

Home Phone

May I leave a detailed message?

Work Phone

May I leave a detailed message?

Cell Phone

May I leave a detailed message?

Date of Birth

What is your occupation?

Marital Status

Partner’s Name

Partner’s Gender

Partner’s Address (if different)

City

State or Province

Zip or Postal Code

Country

Partner’s Date of Birth

Partner’s Occupation

What do you want to talk about in counseling?

How long has the problem been going on?

Is it getting better or worse now?

What makes it better or worse?

Would anyone else be involved in your counselling?

Are you currently in treatment for any medical problems, including taking medication of any type? Please explain.

Is there a concern about alcohol, drug abuse, or overuse of non-prescribed drugs? Please explain.

Is there a concern about violence in your life today? Either from you or towards you? Please explain.

How concerned are you about violence on a scale of 1 to 10 with 10 being the worst.

Is there a concern about suicide? Please explain.

How concerned are you about suicide on a scale from 1 to 10 with 10 being the worst?

Have you had any counseling before?

Where did you go?

What was it concerning?

Is there anything else that you would want the counselor to know before your appointment?

How did you hear about Stacy Finch?

Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu. .rm_next_btn {display:none !important} .rm_noscript_btn {display: block !important}