Intake Form

Ready for your session?

Please ensure to fill this form at least 6 hours before your scheduled session. This form will help us to understand your concerns, and prepare for your session in a thoughtful and personalized way. You may choose to skip any question that you are not comfortable answering. Most questions are optional, however the questions marked with * are mandatory.

Section 1: Basic Details

Please enter a name for future communications.
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Please provide the contact number you used to book the session.
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dd-mm-yyyy
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They will be contacted only in case of an emergency.
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They will be contacted only in case of an emergency.
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Section 2: Background Information

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Living Situation
Relationship Status
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Section 3: Present Concerns

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How long have you been experiencing the symptoms?
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Section 4: Emotional & Mental Health

In the past two weeks, select all that you have experienced:
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Section 5: Physical Health & Rehabilitation Context

Do you have any ongoing physical health condition?
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Section 6: Past Support & Preferences

Have you attended any therapy before?
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Are you currently taking any psychiatric medication?
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Section 7: Safety & Support

Have you recently experienced thoughts of harming yourself or others?
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Do you feel safe currently?
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How did you hear about this service?
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Section 8: Consent & Acknowledgement

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