Client confirmation form

Client ID*: Assessed by*: Assessor’s e-mail*: Date of Assessment Year*:      —20142015201620172018 Month*:  —010203040506070809101112 Day*:       —01020304050607080910111213141516171819202122232425262728293031Department*: —SPTIPTPInternRoster Modality*:—IndividualCoupleFamilyCombinedClient Demographic Data Home language*:     —EnglishFrenchBilingual E/FSpanishHebrewItalianRussian Level of education*: —NoneElementaryHigh SchoolCEGEPUniversity Fee for Therapy Family income*: —$0 – $21,999$22,000 – $26,999$27,000 – $31,999$32,000 – $36,999$37,000 – $41,999$42,000 – $51,999$52,000 – $61,999$62,000

Client file closure form

Client ID*: Closure form filled by*: Form Filler’s e-mail*: Date of last interview:*: Year:         —20142015201620172018 Month:     —010203040506070809101112 Day:           —01020304050607080910111213141516171819202122232425262728293031Closure initiated by*: —ClientTherapistBothOtherInternship end Final closure?:*            YesNo Number of sessions*: Goal of therapy 1: Therapist evaluation 1: 1 – Much