Please fill out the following information to help us better understand your needs and ensure a productive therapeutic experience. (Please feel assured that all information provided will be kept confidential.) Personal Information: Full Name Date Gender Select Gender Male Female Preferred Pronouns Address Phone Number Email Address Emergency Contact Information: Name Relationship to Client Relation Phone Number Therapy Information: 1. Have you received therapy or counselling before? Yes No If yes, please provide past therapy or counselling details: 2. Why are you seeking therapy at this time? 3. Briefly describe your current concerns or challenges: 4. Have you been diagnosed with any mental health conditions? Yes No If yes, please provide mental health conditions details: 5. Are you currently taking any medications for mental health? Yes No If yes, please provide details of medications: 6. Are you currently under the care of a psychiatrist or other healthcare professional? Yes No If yes, please provide details of psychiatrist or other healthcare professional: 7. Have you experienced any traumatic events in the past? Yes No If yes, please provide details of traumatic events: 8. Are there any specific goals you would like to work towards in therapy? 9. Is there any other information you would like to share about yourself that may be relevant to therapy? 10. How did you hear about our therapy services? Online Search Referral Advertisement Other Thank you for taking the time to complete this form. Your responses will assist us in tailoring our therapeutic approach to best meet your needs. Submit
