Potential new patient info form
If you are interested in starting therapy with me, please fill out the below form so I can get an idea of what you are looking for and whether I can accommodate you. 

Some things about me to note:
- I work long-term and so don't tend to take on new patients who are looking for six months or less of therapy
- I work a month in advance so if you are looking for help in the next week or two I won't be able to assist. You can explore therapists near you with immediate availability on www.therapyroute.com
- Please note I run a cash practice so clients pay me directly then claim that back from their medical aid.  
- Please have a look on my website https://jordandutoit.co.za/faq for more frequently asked questions and answers, including my rates and therapy style. 

Email *
What is your preferred name? *
What pronouns do you use? *
What kind of therapy are you looking for? *
Are you happy to pay me directly for sessions and then claim back from medical aid if you would like to use your medical aid?
How did you learn about me?  *
Have you ever been in therapy before? *
What would you be hoping to get from therapy with me? *
How long would you be willing to commit to therapy?
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How often would you ideally come for sessions? I prefer to work weekly but we can discuss this. *
If I can't see you immediately, how long are you willing to be on a waiting list for? *
Have you ever been admitted to a hospital for psychiatric related issues before? *
Do you currently have a psychiatrist? If so, who? *
Is there anything you think would be important for me to know that hasn't been covered in these questions? *
What setting would you need for therapy? *
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