Client Counselling Intake Form

Thank you for choosing t2:4 Counselling to walk alongside you. Please complete all fields.

Email *

May I email you at this address?

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Your contact details
First Name *
Surname *

Date of Birth:

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MM
/
DD
/
YYYY
Gender *

Home address:

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Mobile number:

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(May I leave a voicemail, if necessary?) 
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Emergency contact details

His/Her Full Name:


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His/Her Phone number:

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What is their relationship with you:

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Your GP's details

GP's Name

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GP's Telephone number

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GP's Address

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List of medication and dosage (including contraceptive pill) (If not applicable, N/A)
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Your reason for Counselling

Please give a brief description of why you are seeking counselling:

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What is your goal for counselling?

*

Have you had previous counselling concerning the issue(s) for which you are currently seeking counselling?


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If yes, please provide this additional information.

What was the name of Counsellor/Organisation. 

(N/A if not applicable)

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Duration of counselling and outcome:

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Any additional information you want to share with me?
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