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Intake and Consultation Form
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* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Preferred name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Relationship Status
*
Your answer
Children
Your answer
Address
*
Your answer
Mobile Number
*
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Mobile
*
Your answer
Health issues (Past and/or current)
Doctor’s name and address
*
Your answer
Date of last check-up
Your answer
Medications being taken
Your answer
FROM THE LIST BELOW TICK YOUR AREAS OF CONCERN
Addictions
Drinking
Smoking
Drugs
Phone, video games social media addiction
Compulsive Behaviour
Anxiety
Stress
Fears
Phobias
Panic Attacks
Guilt
Relaxation
Bad Eating Habits
Excess Weight
Anorexia
Bulimia
Exercise
Nail-biting
Depression
Confidence
Self Esteem
Motivation
Achieving Goals
Procrastination
Sexual trauma
Abuse/Trauma
Career Issues
Tension
Nerves
Public Speaking
Concentration and/or Focus
Exams
Memory
Sexual Problems
Fertility
Erectile Dysfunction
Emotional Pain
Physical Pain
Hearing
Sight/Vision
Mobility
Skin Problems
Hair loss
Relationships
Feeling Empty or Incomplete
Childhood Problems
Anger and or Rage
Co-dependency
Not Feeling Good Enough
Feeling Unworthy
Impatience
Sadness
Other:
How motivated are you to work on this / change this?
(from 1 to 10)
*
Low
1
2
3
4
5
6
7
8
9
10
High
What is your presenting problem?
*
Your answer
How does this issue or issues affect you?
*
Your answer
Describe briefly what your childhood was like.
*
Your answer
What do you believe about yourself?
Example: "Sometimes i dont feel safe. "I dont feel good enough ...
*
Your answer
What do you want to feel like after your session? Please go into detail about what you want your life to look like.
*
Your answer
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