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Client Intake Form
Serein Therapy Space
Mahi Kasana - Counselling Psychologist
Thank you for choosing to Connect with me. I appreciate the trust you've placed in me by taking this step toward seeking support. I provide a mental health aid to people through cognitive behavioural therapy and use a client centered and evidence based therapy.This intake form is designed to help me better understand your concerns, background, and goals so I can provide the most appropriate care. All information you share will remain confidential and will be used solely for therapeutic and administrative purposes in accordance with professional ethical guidelines.  

VOLUNTARY PARTICIPATION
Your participation in counselling is completely voluntary. You may choose not to answer any question and are free to discontinue counselling at any time.

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INFORMED CONSENT
Please read the following carefully before proceeding. 
-Counselling is a collaborative process designed to promote emotional wellbeing, personal growth, and psychological health. 
-Every effort will be made to provide a safe, respectful, and supportive environment; however, specific outcomes cannot be guaranteed.
-By selecting "I Agree," you confirm that:
1. I have read and understood the information provided above.
2. I understand the nature and limitations of counselling services.
3. I understand the limits of confidentiality.
4. I have read and understood the cancellation policy.I voluntarily consent to participate in these counselling services.
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Full Name 

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Age *
Date of birth *
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DD
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YYYY
Gender  *

Marital status

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Current address: 

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Contact Number *
May we message you on this number? *
E Mail Address *
May we send email to you on this I'd ? *
Emergency Contact (Name, Phone Number, Relation) *
How did you hear about me ? *
PRESENTING CONCERN 
What brings you to therapy at this time?  
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How long have you experiencing these concern ? *
What difficulties are these concern causing in your daily life? *

MENTAL AND PHYSICAL HEALTH

Are you currently receiving psychological services, professional counseling, psychiatric services, or any other mental health services?

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If yes, specify your reason for changing

Are you currently taking any psychiatric prescription medication? 

-If yes, please list:

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Counselling session scheduled 
 Availability of time
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Availability of days *

Consent & Declaration

By selecting "I Agree," I confirm that:

I have read, understood, and agree to the terms and conditions outlined above.

The information I have provided in this form is true and complete to the best of my knowledge.

I understand that submitting this intake form does not guarantee or confirm a counselling appointment. Session bookings are subject to the counsellor's availability.


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