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.
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Email *
Name *
Current date *
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Date of birth *
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Phone number *
Is it okay to use this number to text in case of cancellations or for general communication?
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Brief description of the support you are looking for. What are your therapeutic goals and what you are hoping to obtain from therapy? *
Have you ever experienced counselling/psychotherapy in the past?
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Please share brief details of any historic therapeutic work including insights and challenges experienced
What would you like me to know about your family history? Please include details of any siblings and relationship between your parents.
What is your current living situation? Are you married, and do you have any children? If so, please list ages of your children.
What are some of the significant experiences in your life as a child?
What are some of the significant experiences in your life as an adult?
Is there any history of addiction within your family?
What is your relationship to substances?
How would you describe your self care practices? What or who do you typically turn to for comfort? Who would you consider to be your support network?
Is there anything else you would like me to know about you before we meet?
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