Adult Intake Questionnaire

This intake questionnaire will help me get to know you, and what brings you to therapy.

Please complete and return before your first visit.

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?

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?

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