Full Consultation Intake Form

Welcome — I’m glad you’re here!
This form is intended to help me understand what you hope to achieve through therapy.

Basic Information

Last Name

First Name

Preferred Name

Preferred Language

Phone Number

Country / Region

Address

City & Postal Code

Date of Birth Format: mm/dd/yyyy

Workplace

Emergency Contact & Phone

Have you received therapy before? If yes, when did it start and end, and what was the experience like?

What brings you to therapy at this time?

Your goals and expectations for therapy

Are you currently taking medication? Names, dosage, and how long have you been taking them?

Have you ever engaged in self-harm?

Anything else you would like me to know?

I have read, understood, and agreed to the above policies and financial terms.

First Name

Last Name

Signature