Individual Counselling Intake Form

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Full Name *

Email Address *

Phone number *

DOB *

Briefly note any medication that you take for your mental health.

Briefy note any mental health struggles in your family history. *

Briefy note any previous mental health struggles of your own. *

Have you had counselling before? If yes, what was your experience? *

Please mention why you're seeking counselling support now. *

On average, how much alcohol do you consume each week? *

Missed Appointments & Short Notice Cancellations

A missed appointment is still charged at full cost. When you book a time, it means no one else can take it. If you don't give sufficient notice (at least 6 hours), I have no way to give this time to someone else who may really need help and support. They would miss out on counselling, and I would miss out on the income for that hour.

If cancelling at short notice (within 6 hours), the charge is 50%.

If I can fill the session, then no charge applies.

Please initial and date to indicate that you have read the previous paragraph and that you have filled out this form yourself. *

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