Therapy Questionnaire

Please fill out this form as openly and honestly as possible. 

The more detail you provide, the better I can understand your needs and make the most of our time together during the call. This is the first step in our exploration, helping to identify patterns, challenges, and areas for growth.

All information is completely confidential and used solely for our work together. There are no right or wrong answers — this is simply a space for self-reflection and clarity

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Email *
What is your full name? *
How old are you? *
Where do you live?
 *
What is your occupation? *
What are you hoping to achieve out of therapy? What would the ideal outcome look like?
What challenge(s) would you like to explore?
What steps, if any, have you taken to overcome the challenges?
Are you experiencing any of the following?  Tick all that apply
If you've selected any, can you explain more on what you're experiencing?

Are you currently taking any medications, supplements, or substances (including alcohol or recreational drugs) that affect your mental or physical health? Please list them

Do you have any current or past medical conditions (e.g. chronic illnesses, surgeries, significant injuries) that you think are relevant to share?

When facing challenges or stress, what coping mechanisms or strategies do you typically use? Have they been effective?

Are there any habits you wish to change?  (To start, to stop, to do more of, to do less of)
How is your relationship with your immediate family?  What's important for me to know?
Do you have friends, family members, or community resources that you can rely on for support? Please describe your support system.

Have you previously worked with mental health professionals (e.g. psychiatrist, psychologist, psychotherapist, counsellor)? If yes, please share details about the experience, including what approaches you found beneficial or unhelpful

Are there any cultural, religious, or personal beliefs that are important for me to know to better support you?
Do you have any expectations or preferences from me in my role as a therapist?
What can I expect from you as a client?
Is there anything else you would like to share that I should know?
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