Client Intake Questionnaire For Face-to-Face Online Counselling/Therapy
This is a questionnaire for a service user to fill in and then be assigned a therapist. All information will be kept confidential.


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Email *
1. Name & Surname *
2. Date of birth *
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DD
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3. ID Card Number *
4. Gender *
5. Age *
6. Status *
7. Email Address *
8. Are you currently residing in Malta or Abroad? *
9. Address *
10. Mobile Number *
11. Emergency Contact Name *
11a. Emergency Contact Number *
12. Current Occupation *
13.  Are you currently frequenting any other mental health professional? (e.g. psychotherapist/psychologist/counsellor).  *
14. Why do you wish to apply for the free online/face-to-face counselling/therapy services of kellimni.com? *
15. How long have you been feeling this way/experiencing these difficulties? More than a year/ more than 6 months / less than 6 months  *
16. Have you previously been referred to or received any type of mental health service (psychotherapy, psychiatric, counselling, etc.)? *
16a. If you answered yes to the above, what was the reason for contacting mental health services?
17. Are you experiencing suicidal ideation now or in the past? *
18.  Have you engaged in self-harm currently or in the past? *
19. Have you been prescribed medication for your current symptoms? If so, specify the type and dosage.  *
20. What medium would you prefer to use for your counselling sessions? *
21. Would you prefer a male or female counsellor/therapist? (Your answer does not necessarily guarantee the preferred gender, depending on availability) *
22. On a weekly basis, at what times and days would you be available for counselling/therapy? *
23. Additional Information that is deemed to be important to be known by the professional:
Consent to forward personal contact details to assigned professional after complying with terms and condition of the service. *
GDPR: By signing this form you give your express consent for the use of personal data and the sensitive personal data you have provided to SOS Malta, its employees, counsellors and advisors for the purposes of Face-to-Face/ Online Counselling/Therapy and other services you may request or which are provided for in our agreement. The personal data and sensitive personal data on this form: Shall be processed fairly, shall be obtained and processed only for  the provision of our services, programme records and statistics, and shall not be kept for longer than three years from the termination of our relationship (unless required longer for our legitimate purposes, specifically for any legal purposes). Appropriate measures shall be taken against unauthorized or unlawful processing of personal data and against accidental loss or destruction of or damage to the mentioned data. I agree and I understand that this questionnaire shall process details fairly, retain details for record keeping, and not keep details for longer than three years. I agree that no recording of sessions are permitted; online or face-to-face. By accepting, I attest that the information I have provided on the questionnaire is true and accurate. For further information on SOS Malta’s data protection policies and to provide you with  your rights under GDPR, kindly contact the SOS Malta Board responsible for data protection for SOS Malta’s Data Privacy Notice.

NB: Kindly know that information will be processed within 4-5 working days. *
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