Adult Intake Questionnaire

Thank you for choosing this practice to seek support. Please complete this intake form before your first visit. It will help me get to know you, and what brings you to therapy.

Please be assured that all information provided is completely confidential, and will be stored safely, in accordance with the Privacy Act, 1988.

Name

Date of Birth

Address

Preferred Phone

How did you hear about me?

Permission to add you to my email subscriber list for tips on parenting support? Yes / No

Relationship Status

Current Medications

Current GP

Current Medical Concerns / Diagnoses

Previous medical/mental health related history

Are you currently seeing another counsellor, psychologist or psychotherapist? Yes / No

Have you seen someone in the past?

What was helpful, or not helpful with previous therapy??

Any recurring dreams?

Any recurring life patterns or stories?

Any addictions or addictive tendencies?

Emergency contact person 1

Relationship to you:

Phone

Why are you here? What would you like to achieve from your counselling experience?

Adult Intake Questionnaire

Helpful Links

Contact Information

Join Our Mailing List