Client Intake Form
At Therapy in Barcelona our goal is to help you feel comfortable, understood, and heard.

To enable us to match you with the right professional or offer appropriate referral option/s, please fill out the following as completely as possible and press SUBMIT at the end.

This form collects your name, email and phone number and info so that we can correspond with you and help you. Check out our privacy policy for the full story on how we protect and manage your submitted data: https://www.therapyinbarcelona.com/privacy-policy/

This information is confidential and will be treated with respect and care.

If you have any queries, please contact us at info@therapyinbarcelona.com

PLEASE NOTE THAT IF YOUR ISSUES ARE OUTSIDE OF OUR FIELD OF EXPERIENCE AND EXPERTISE, WE MAY SUGGEST ALTERNATIVE SERVICES WHICH MAY BE MORE SUITABLE FOR YOU.

You must check the criteria for reimbursement with your insurer. We do not guarantee, or advise on, reimbursement from insurers.
Email address *
Your complete name *
Your answer
Preferred name
Your answer
Parent/Guardian names (for children under 18)*
Your answer
Current address in Barcelona *
Your answer
City *
Your answer
Postal code *
Your answer
Mobile phone (By giving us your phone number, you are permitting us to leave messages for you via voicemail, text or Whatsapp should we not be able to contact you, unless you state otherwise.) *
Your answer
Date of Birth (DD/MM/YYYY) *
Your answer
Country of Origin
Your answer
Current Occupation
Your answer
Language/s you would like to have therapy in, apart from English (if possible)? *
Your answer
Do you prefer a male or female therapist? *
Education (grade completed, degree, postgraduate)
Your answer
Person to alert in the event of an emergency (preferably someone in the same city you are now living in) *
Your answer
Relationship to you (partner, friend, mother) *
Your answer
Emergency Contact Phone Number *
Your answer
Your relationship status *
Your partner's 1st name (if applicable)
Your answer
Your Children (gender, age) (if applicable)
Your answer
Please describe any significant current or past relevant medical problems
Your answer
Please list any medications you currently take. Include prescription and over-the-counter medications and the dosage of each *
Your answer
Have you ever had previous therapy, psychological care or counselling? *
Required
If yes, please give the name of the professional(s), the months you saw them (e.g., Nov 12 - Feb 13), and the nature of the difficulty at the time.
Your answer
Have you ever been hospitalised for a psychological difficulty? *
Required
If yes, please give the dates and the nature of the difficulty at the time:
Your answer
What brings you to therapy? *
Required
In your own words, what is the nature of the concern that you wish to address in your sessions? Feel free to describe this in as much or as little detail as you wish: *
Your answer
In order for counselling to be most effective it helps to have a clear and specific goal. You may find it difficult to express your hopes for counselling in the form of a goal, but please make at least an initial effort. You can discuss this further with your counsellor. Feel free to list more than one goal if you wish. *
Your answer
Additional comments.
Your answer
Let us know if you have certain days or times you need to schedule your appointments. If you are flexible, please click the I'm flexible option. Please be clear so we can book an appointment at the best time for you. *
Anything else you want us to know about your schedule/availability? Please be clear so we can book an appointment at the best time for you. The more availability you offer, the more quickly we can offer you an appointment.
Your answer
For counselling to be effective it does require a commitment of both time and finances. An important question to ask is whether or not you can afford to delay getting the help needed.Therapy usually requires a commitment of at least 4-8 sessions to start with. Our fees are as follows: 70 Euro (Inc. VAT) for a 50 minute individual session 80-90 Euro (Inc. VAT) for a 50 minute couple or family session . Please indicate your level of commitment here: *
How did you hear about us? Let us know the specific website, school, person or place who referred you so we can continue that referral relationship. Thanks! *
Your answer
Would you like us to: *
PRIVACY POLICY By clicking YES, you indicate you have read and agree to our privacy policy https://www.therapyinbarcelona.com/privacy-policy/ *
STAY CONNECTED! We'd like to send you occasional emails, like info about expat therapy groups, events, etc at Therapy in Barcelona. *
Today's Date *
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