Therapy Intake Form
First name
Your answer
Last name
Your answer
Phone number
Your answer
E-mail address
Your answer
How old are you?
What is your marital status
What is your occupation at the moment?
What is the reason for your consultation?
Required
When did this difficulty begin?
What type of therapy are you interested in?
Required
Have you ever consulted with a mental health professional before?
Are you taking any psychiatric medication?
Have you ever attempted suicide?
Have you attempted any self-injury in the last few months?
When are you available to meet your therapist? (You can select more than one)
Required
At which MindSpace location(s) are you willing to attend meetings? (You can select more than one)
Required
What is your preferred language for therapy
How did you hear about MindSpace?
Notes
Your answer
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