Client Intake Questionnaire - The Lighthouse Counselling
Please fill in the information below and before your first session. Please note: information provided on this form is protected as confidential information.

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Full name (First name, Last name) *
Phone (please provide country code) *
Email *
Age *
Marital Status *
Gender *
Emergency contact number (please state family, friends, etc.)
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? If yes, when was that?:
Are you currently / previously been taking any prescription medication? If yes, please list:
How would you rate your current physical health?
Very Good
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. How would you rate your current sleeping habits?
Very Good
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Are you currently experiencing overwhelming sadness, grief or depression? If yes, please provide details:
Are you currently experiencing anxiety, panics attacks or have any phobias? If yes, please provide details:
Are you currently in a romantic relationship? If yes, please rate your relationship from 1 (poor) to 10 (very good)
What significant life changes or stressful events have you experienced recently?
In section below, identify if there is any history of any of the following. If yes, please provide details:
Are you currently employed? If yes, please rate from 1 (poor) to 10 (very good):
Do you consider yourself to be spiritual or religious? If yes, describe your faith or belief:
What would you like to accomplish out of your time in the therapy?
Please suggest your preferred time slots and indicate "face to face / online" for your first session: *
Please indicate your preferred choice of therapist *
How did you find us (please indicate the source)? Otherwise, referred by (if any)
Important: please read below link before our sessions. By submitting this form you are agreeing to confidentiality terms at the link. Thank you.
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