Intake Form
Please take the time to read through and fill in this form. Know that you are welcome to answer all questions with as much or as little detail as you feel comfortable. This form is confidential. I look forward to meeting you and working together in support of your needs.
Email address *
Name *
Your answer
Current date *
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Date of birth *
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Phone number *
Your answer
Is it okay to use this number to text in case of cancellations or for general communication?
Brief description of the support you are looking for. What are your therapeutic goals and what you are hoping to obtain from therapy? *
Your answer
Have you ever experienced counselling/psychotherapy in the past?
Please share brief details of any historic therapeutic work including insights and challenges experienced
Your answer
What would you like me to know about your family history? Please include details of any siblings and relationship between your parents.
Your answer
What is your current living situation? Are you married, and do you have any children? If so, please list ages of your children.
Your answer
What are some of the significant experiences in your life as a child?
Your answer
What are some of the significant experiences in your life as an adult?
Your answer
Is there any history of addiction within your family?
Your answer
What is your relationship to substances?
Your answer
How would you describe your self care practises? What or who do you typically turn to for comfort? Who would you consider to be your support network?
Your answer
Is there anything else you would like me to know about you before we meet?
Your answer
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