Counselling Intake & Appointment - New Client
Thank you for your interest in joining in a therapeutic conversation with QUEERFLEX. This form is confidential and will only be seen by Michelle. For more information about counselling at Queerflex please click [here]
Email address *
Name (As you would like to be called) *
Your answer
Phone Number *
Your answer
Birthday *
MM
/
DD
/
YYYY
Gender
Your answer
Pronoun
Your answer
Are you a QUEERFLEX member? *
What times are you available?* (please indicate a time frame - you will be emailed to confirm a specific time)
Please select all that apply
10:30-2pm
3-6pm
Monday
Do you currently have employee benefits for counselling *
What brings you to counselling today? *
Your answer
Are you experiencing suicidal thoughts? *
What is you current living situation? (Roommates, parents, alone, other caretakers, etc) *
Your answer
Have you ever recieved a mental health diagnosis? *
Please share any details about your diagnosis you feel comfortable sharing.
Your answer
Have you had any previous experience with counselling? *
On a scale of 1-10 how ready to do feel to make changes? *
Please outline any medical diagnoses or chronic illnesses you are comfortable sharing.
Your answer
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