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.
This field is required.
Please provide the contact number you used to book the session.
This field is required.
dd-mm-yyyy
This field is required.
This field is required.
This field is required.
This field is required.
Your emergency contact details will remain confidential and will only be used in rare situations where there is a serious concern about your immediate safety and wellbeing.
This field is required.
Your emergency contact details will remain confidential and will only be used in rare situations where there is a serious concern about your immediate safety and wellbeing.
This field is required.

Section 2: Background Information

This field is required.
Living Situation
Relationship Status
This field is required.

Section 3: Present Concerns

This field is required.
How long have you been experiencing these concerns or difficulties?
This field is required.
This field is required.
This field is required.

Section 4: Emotional & Mental Health

In the past two weeks, select all that you have experienced:
This field is required.

Section 5: Physical Health & Rehabilitation Context

Do you have any ongoing physical health condition?
This field is required.

Section 6: Past Support & Preferences

Have you attended any therapy before?
This field is required.
This field is required.
Are you currently on any prescribed medication for psychological or emotional concerns?
This field is required.
This field is required.
This field is required.

Section 7: Safety & Support

Have you recently experienced thoughts of harming yourself or others?
This field is required.
Are you feeling safe at the moment?
This field is required.
How did you hear about this service?
This field is required.

Section 8: Consent & Acknowledgement

This field is required.
This field is required.
This field is required.
This field is required.

Scroll to Top