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Intake for free therapy
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Email
*
Your email
First and last name ( what you go by)
Your answer
Address
Your answer
Have you had therapy before?
Yes
No
If yes, what was you experience like?
Excellent
Good
Fair
Poor
Other:
Clear selection
What type of therapy?
Cognitive-Behavioral Therapy
Dialectical Behavior Therapy
Exposure Therapy
Interpersonal Therapy
Mentalization-Based Therapy
Psychodynamic Therapy
Animal-Assisted Therapy
Emotion-Focused Therapy
Family Therapy
Group Therapy
Mindfulness-Based Therapy
Creative Arts Therapy
Other:
Who is your support system?
Parents
Siblings
Best friend
Co-worker
Spouse/Partner
Other:
How do you cope with stress
Eating
Listen to music
Physical activities
Sleep
Read
Meditate
Praying/Visit place of religion eg. Church?
Yoga
Massage
Video games
Watch TV
Other:
Current problems
Feeling blue
low motivation to get things done
Fatigue
Worry
Trouble falling asleep
Feeling hopeless
Irritability
Feeling guilty
loss of interest in things, people or activities
Trouble concentrating
What goals do you hope to accomplish as a result of our working together?
Your answer
What is your education history?
Your answer
Current Employment
Your answer
How do you describe yourself? 5 adjectives
Your answer
Which topics interest you?
food
movement
career choices
intuition
confidence
dating/sex
drugs
self esteem
self awareness
Other:
Best time of day for booking sessions
Morning
Afternoon
Evening
online
in person - North York
Other:
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