Intake Form

Please complete this form before your first appointment.

Need a pause? Take a break and return when you feel ready. Grounding resources live in the Client Care Hub.

Contact

First Name (required)

Last Name (required)

Email (required)

Mobile Phone Number (required)

Country (required)

Address Line 1 (required)

Address Line 2

Suburb (required)

State (required)

Postcode (required)

Date (dd/mm/yyyy) (required)

Occupation

Are you currently in any form of relationship?

Do you have any children?

Next of Kin (In case of emergency)

Phone number for Next of Kin

How would you consider your general health?

1 — 5 scale

Have you previously seen a counsellor or psychologist?

Are you on any medication from any previous issue?

If yes, medication details

Are you currently experiencing overwhelming sadness, grief or depression?

Have you ever had any suicidal thoughts?

Has any family member identified with any mental health issue?

How would you consider your sleeping habits?

1 — 5 scale

How would you rate your current physical health?

1 — 5 scale

Do you do any form of exercise? If so, how often?

Are you currently experiencing any form of chronic pain?

Are you currently using any alcohol or drugs for pain management?

Have you recently used any recreational drugs?

What is the main reason/s you are seeking therapy?

Is there any other information you think might be important?