Client Intake Form
Welcome to Therapy in Barcelona. To make the most of each appointment you have with us, please write down some basic information in advance of your first appointment. Please fill out the following as completely as possible. This information is confidential.

In order to be allocated a therapist as soon as possible, complete this form and submit.

Please read our privacy policy at https://www.therapyinbarcelona.com/privacy-policy/

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.

Email address *
Your complete name *
Your answer
Preferred name
Your answer
Current address *
Your answer
City *
Your answer
Postal code *
Your answer
Telephone *
Your answer
Age
Your answer
Date of Birth (DD/MM/YYYY) *
Your answer
Birthplace
Your answer
Language/s you would like to have therapy in, apart from English (if possible)? *
Your answer
Education (grade completed, degree, postgraduate)
Your answer
Current Occupation
Your answer
Person to alert in the event of a medical emergency (preferably someone in the same city you are now living in) *
Your answer
Relationship to you *
Your answer
Phone *
Your answer
Your relationship status *
Spouse/partner's 1st name (if applicable)
Your answer
Spouse/partner's age (if applicable)
Your answer
Years in relationship (if applicable)
Your answer
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 clinician(s), the months you saw them (e.g., Nov 06 - Feb 07), 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
In your own words, what is the nature of the concern that you wish to address in therapy? Feel free to describe this in as much or as little detail as you wish: *
Your answer
In order for therapy to be most effective it helps to have a clear and specific goal. You may find it difficult to express your hopes for therapy in the form of a goal, but please make at least an initial effort. You can discuss this further with your therapist. 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. * *
Anything else you want us to know about your schedule/availability?
Your answer
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
By clicking YES, you indicate you have read and agree to our privacy policy https://www.therapyinbarcelona.com/privacy-policy/ *
Today's Date *
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A copy of your responses will be emailed to the address you provided.
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