ADHD Intake ADHD Intake FormΔ Notify General InformationWe’re here to help you on your journey to better mental health. To secure your 30-minute intake appointment, a non-refundable commitment fee of $40 is required. This fee covers the professional time one of our therapists dedicates to carefully reviewing your intake form, including the initial screening that is part of the intake process. Should you decide to proceed with additional ADHD-related services—such as further assessment, skills training, or clinical therapy—the $40 will be credited toward your initial appointment. This policy ensures that each client receives thoughtful attention from the outset and supports an efficient scheduling process. Please note that commitment fee is waived for First Nations clients. Let's start with your name, phone number, email address, and birth date.Your First NameYour Last NameYour Best Phone NumberYour Best EmailDate of Birth (Month/Day/Year)Save & ResumePreviousNextCultural HeritageNow some questions about your Cultural Heritage. This section is essential to determine if you may qualify for NIHB or MN-SK funding.Are you a Canadian Indigenous Person?- Select -NoYes, First Nations or InuitYes, but non-statusYes, MN-SK CitizenPlease enter your full treaty card numberPlease enter your MN-SK Citizenship numberPreviousNextYour SymptomologyLet's briefly look at your mental health and ADHD-related symptoms and why you are seeking supports.SymptomsPresentPersistent anxietyPersistent low moodPersistent stressI feel restlessCurrently grievingPersistent difficulties with sleepingI feel tired all the timeCurrently struggling with addictionsLittle interest or pleasure in doing things- Select -Not at allSeveral daysMore than half the daysNearly every dayFeeling down, depressed or hopeless- Select -Not at allSeveral daysMore than half the daysNearly every dayFeeling nervous, anxious or on edge- Select -Not at allSeveral daysMore than half the daysNearly every dayNot being able to stop or control worrying- Select -Not at allSeveral daysMore than half the daysNearly every dayPreviousNextCurrent SupportsLet's briefly look at current supports, medication, and reports.Currently taking prescription medication for your ADHD symptoms or mental health?- Select -NoYes, for mental healthYes, for ADHDEnter medication name and current dosageHave you seen a mental health therapist within the last 12 months?- Select -NoYesIf you have an ADHD diagnostic report, please upload (PDF or DOCX only). If you do not have a digital copy, you can submit the report laterChoose File PreviousNextADHD Specific QuestionsPlease answer the following 6 questions as pre-screening for a potential ADHD assessment.How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? - Select -NeverRarelySometimesOftenVery OftenHow often do you have difficulty getting things in order when you have to do a task that requires organization? - Select -NeverRarelySometimesOftenVery OftenHow often do you have problems remembering appointments or obligations? - Select -NeverRarelySometimesOftenVery OftenWhen you have a task that requires a lot of thought, how often do you avoid or delay getting started? - Select -NeverRarelySometimesOftenVery OftenHow often do you fidget or squirm with your hands or feet when you have to sit down for a long time? - Select -NeverRarelySometimesOftenVery OftenHow often do you feel overly active and compelled to do things, like you were driven by a motor?- Select -NeverRarelySometimesOftenVery OftenWhy do you think you might have ADHD?Appointment Commitment FeeFee: $40.00Pay with Card (Stripe)Submitting your Intake RequestPlease read the following carefully Submitting this form will forward my information to STG Health Services Inc. I understand that incomplete forms or inquiries irrelevant to counselling and requesting an intake appointment will be discarded. I understand that I will receive a text message and an email about making an intake appointment. I understand that submitting this form does not provide crisis management or urgent mental health support. If I need help now, I will call the Health Line 811 immediately or contact 911. All marketing and spam submissions will be deleted. I agree and understand the above statements Previous Request Priority Intake
