Therapy Intake Form
First name *
Your answer
Last name *
Your answer
Phone number *
Your answer
E-mail address *
Your answer
How old are you? *
What is your marital status *
What is your occupation at the moment? *
What is the reason for your consultation? *
When did this difficulty begin? *
What type of therapy are you interested in? *
Have you ever consulted with a mental health professional before? *
Are you taking any psychiatric medication? *
Have you ever attempted suicide? *
Have you attempted any self-injury in the last few months? *
When are you available to meet your therapist? (You can select more than one) *
At which MindSpace location(s) are you willing to attend meetings? (You can select more than one) *
What is your preferred language for therapy *
How did you hear about MindSpace? *
Your answer
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