Client Intake Form

Client Intake Form
Please note that you need to fill this form and send the same to me at least one day prior to your first session. This will help me optimise time in the first session, so that I can address your concerns.

Personal Information

Gender
Marital status

Emergency Contact

Please mention the referring doctor/professional. If self-referred, how did you find out about me?
Please briefly describe the primary issue or concern that you would like to address in counselling
Counselling History
Have you received counselling or therapy before?
Medical History
Are you currently taking any medication for physical/chronic/emotional or psychological issues?
Background Information:
Marital Status
Living Situation

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