Client ID*: Assessed by*: Assessor's e-mail*: Assessed Year*:---20142015201620172018201920202021 Month*: ---010203040506070809101112 Day*:01020304050607080910111213141516171819202122232425262728293031 Dept.*: ---SPTIPTPInternRoster Modality*: ---IndividualCoupleFamilyCombined Client home language*: ---EnglishFrenchBilingual E/FSpanishHebrewItalianRussian Level of education*: ---NoneElementaryHigh SchoolCEGEPUniversity Number in Family:* Dependants*: Sliding scalePrivate 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 - $71,999$72,000 - $81,999$82,000 - $91,999>$92,000Not required for private clients Session fee ($)*: Basic problem 1:---DepressionAddictionRelationship/CoupleRelationship/FamilyRelationship/Family of OriginSexual OrientationSexual DysfunctionEating DisorderStress/BurnoutAnxietyAnger ManagementGriefADDOther Other problem 1: Goal of therapy #1: Basic problem 2:---DepressionAddictionRelationship/CoupleRelationship/FamilyRelationship/Family of OriginSexual OrientationSexual DysfunctionEating DisorderStress/BurnoutAnxietyAnger ManagementGriefADDOther Other problem 2: Goal of therapy #2: Basic problem 3:---DepressionAddictionRelationship/CoupleRelationship/FamilyRelationship/Family of OriginSexual OrientationSexual DysfunctionEating DisorderStress/BurnoutAnxietyAnger ManagementGriefADDOther Other problem 3: Goal of therapy #3:
