Client Intake Form
**We offer online sessions and our office at C/Paris 162 Barcelona is open for face to face sessions from May 11 2020.**
At Therapy in Barcelona our goal is to help you feel comfortable, understood, and heard.
The relationship you have with your therapist, in addition to the work you put in, will be key to a positive outcome to your therapy. 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 information is confidential and will be treated with respect and care.
If you have any queries, please contact us at
PLEASE NOTE THAT IF YOUR ISSUES ARE OUTSIDE OF OUR FIELD OF EXPERIENCE AND EXPERTISE, WE WILL 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.
Our offices are open for face to face sessions from May 11 2020. We also provide online sessions. Do you prefer face to face sessions at our office or online sessions?
Face to Face Sessions from May 11 2020
Online Sessions for now (you can always move to in person sessions later)
Your complete name
Parent/Guardian names (for children under 18)*
Current address in Barcelona including postal code (or address in country you are residing in if not Barcelona)
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.)
Date of Birth (DD/MM/YYYY)
Country of Origin
Language/s you would like to have therapy in, apart from English (if possible)?
Do you prefer a male or female therapist?
Male, but will accept a female therapist if no male therapist is available
Female, but will accept a male therapist if no female therapist is available
Person to alert in the event of an emergency (preferably someone in the same city you are now living in) and their relationship to you (partner, friend, mother)
Emergency contact phone number (indicate country code)
Your relationship status
Your partner's 1st name (if applicable)
Your Children (gender, age) (if applicable)
Please describe any significant current or past relevant medical problems
Please list any medications you currently take. Include prescription and over-the-counter medications and the dosage of each
Have you ever had previous therapy, psychological care or counselling?
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.
Have you ever been hospitalised for a psychological difficulty?
If yes, please give the dates and the nature of the difficulty at the time:
What brings you to therapy?
Feelings of depression
Feelings of anxiety
Adjustment to living abroad/ in Barcelona
Relationship Issues (Individual)
Relationship (Counseling with partner)
Counseling for child
Counseling for adolescent
Psychiatric Problem (Schizophrenia, Psychosis, Bipolar Disorder, other) PLEASE SPECIFY in the question below
Feeling suicidal (we are not a crisis service, please present at your local hospital emergency department for immediate help)
Domestic Violence (We are not a crisis service, and our service is not appropriate for you if you are in immediate danger so please present at your local hospital emergency department for immediate help)
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:
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.
Let us know if you have certain days or times you need to schedule your appointments. If you are flexible, please select the "I'm flexible" option. Please be clear so we can book an appointment at the best time for you.
Monday – Friday 0900-1200
Monday – Friday 1300-1600
Monday – Friday 1700-2100
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.
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 or 80 Euro (Inc. VAT) for a 50 minute couple or family session. Please indicate your level of commitment here:
I am willing to commit the time and finances to the counselling process
I am unable to commit the time and finances to the counselling process
I am about to leave Barcelona so I can't commit the time
I only want 1-2 sessions
If you looked at our Meet the Team page on the website, do you have any preference for a therapist you would like to work with? You can suggest more than one, but please note we cannot guarantee therapist availability or fit with your concerns.
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!
Facebook Support Group
Recommendation from friend
Referred by school, Dr or other
Would you like us to:
Go ahead, match you with a suitable therapist, and book an appointment for you
Provide more information (we will be in contact with you to offer you a schedule of times for a discovery call)
STAY CONNECTED! We'd like to send you occasional emails, like info about expat therapy groups, events, etc at Therapy in Barcelona.
YES please, I'd like to hear about info and events by email
NO thanks, I don't want to hear about info and events by email
Send me a copy of my responses.
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