Client Intake Form
**We offer  online sessions and our office at C/Paris 162 Barcelona is open for face to face sessions from May 11 2020.**

At Therapy in Barcelona our goal is to help you feel comfortable, understood, and heard.

The relationship you have with your therapist, in addition to the work you put in, will be key to a positive outcome to your therapy. To enable us to match you with the right professional or offer appropriate referral option/s, please fill out the following as completely as possible and press SUBMIT at the end.

This form collects your name, email and phone number and info so that we can correspond with you and help you. Check out our privacy policy for the full story on how we protect and manage your submitted data:  https://www.therapyinbarcelona.com/privacy-policy/ 

This information is confidential and will be treated with respect and care.

If you have any queries, please contact us at info@therapyinbarcelona.com

PLEASE NOTE THAT IF YOUR ISSUES ARE OUTSIDE OF OUR FIELD OF EXPERIENCE AND EXPERTISE, WE WILL SUGGEST ALTERNATIVE SERVICES WHICH MAY BE MORE SUITABLE FOR YOU.

You must check the criteria for reimbursement with your insurer. We do not guarantee, or advise on, reimbursement from insurers.

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Email *
Our offices are open for face to face sessions from May 11 2020. We also provide online sessions. Do you prefer face to face sessions at our office or online sessions? *
Your complete name *
Parent/Guardian names (for children under 18)*
Current address in Barcelona including postal code (or address in country you are residing in if not Barcelona) *
Mobile phone (By giving us your phone number, you are permitting us to leave messages for you via voicemail, text or Whatsapp should we not be able to contact you, unless you state otherwise.) *
Date of Birth (DD/MM/YYYY) *
Occupation
Country of Origin
Language/s you would like to have therapy in, apart from English (if possible)? *
Do you prefer a male or female therapist? *
Person to alert in the event of an emergency (preferably someone in the same city you are now living in) and  their relationship to you (partner, friend, mother) *
Emergency contact phone number (indicate country code) *
Your relationship status *
Your partner's 1st name (if applicable)
Your Children (gender, age) (if applicable)
Please describe any significant current or past relevant medical problems
Please list any medications you currently take.  Include prescription and over-the-counter medications and the dosage of each *
Have you ever had previous therapy, psychological care or counselling? *
Required
If yes, please give the name of the professional(s), the months you saw them (e.g., Nov 12 - Feb 13), and the nature of the difficulty at the time.
Have you ever been hospitalised for a psychological difficulty? *
Required
If yes, please give the dates and the nature of the difficulty at the time:  
What brings you to therapy? *
Required
In your own words, what is the nature of the concern that you wish to address in your sessions?  Feel free to describe this in as much or as little detail as you wish:   *
In order for counselling to be most effective it helps to have a clear and specific goal. You may find it difficult to express your hopes for counselling in the form of a goal, but please make at least an initial effort.  You can discuss this further with your counsellor.  Feel free to list more than one goal if you wish. *
Additional comments.
Let us know if you have certain days or times you need to schedule your appointments. If you are flexible, please select the "I'm flexible" option. Please be clear so we can book an appointment at the best time for you. *
Required
Anything else you want us to know about your schedule/availability? Please be clear so we can book an appointment at the best time for you. The more availability you offer, the more quickly we can offer you an appointment.
For counselling to be effective it does require a commitment of both time and finances. An important question to ask is whether or not you can afford to delay getting the help needed. Therapy usually requires a commitment of at least 4-8 sessions to start with. Our fees are as follows: 70 Euro (Inc. VAT) for a 50 minute individual session  or 80 Euro (Inc. VAT) for a 50 minute couple or family session. Please indicate your level of commitment here: *
If you looked at our Meet the Team page on the website, do you have any preference for a therapist you would like to work with? You can suggest more than one, but please note we cannot guarantee  therapist availability or fit with your concerns.
How did you hear about us? Let us know the specific website, school, person or place who referred you so we can continue that referral relationship. Thanks! *
Would you like us to: *
PRIVACY POLICY By clicking YES, you indicate you have read and agree to our privacy policy https://www.therapyinbarcelona.com/privacy-policy/  *
STAY CONNECTED! We'd like to send you occasional emails, like info about expat therapy groups, events, etc at Therapy in Barcelona. *
Today's Date *
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