Therapy Intake Form

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Therapy Intake Form

Congratulations on taking the first step towards improving your mental health!

How it works:

1) Fill out this Intake Form
2) I will reach out to you over email to fix an appointment
3) Initial assessment session
4) Weekly sessions, if we are a good fit.

All sessions will be conducted over a zoom video call.

Full Name *

Age *

Pronouns *

She/Her

He/Him

They/Them

Prefer not to say

Other:

Primary Language *

Occupation *

City/State *

Phone Number/Whatsapp *

Email ID *

How did you hear about me? *

What is your reason for seeking therapy? *

Have you sought therapy before? *

Yes

If yes, when?

What are your expectations from therapy? *

Have you been/are you currently on any psychiatric medication? *

Yes

If yes, please list down the prescribed medication + when it was prescribed.

Have you ever been hospitalised for any psychiatric reason? *

Yes

If yes, when + for what reason?

Have you ever had thoughts about suicide? *

Yes, in the past

Yes, currently experiencing them

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