THERAPY CLIENT INTAKE FORM

PERSONAL INFORMATION

First Name

Last Name

Date of birth

Gender

Male

Female

Other

Prefer not to say

Phone *

Address

Street Address

City

State

Country

Postal code

Emergency Contact (Name, Relationship, Phone):

MENTAL HEALTH AND MEDICAL HISTORY

Have you previously received therapy or counselling of any kind?

Yes

No

If yes, please provide details (e.g., duration, reasons for therapy, outcomes):

Have you ever been diagnosed with a mental health condition?

Yes

No

If yes, please list the condition(s), date of diagnosis and any treatment received:

Are you currently taking any medications?

Yes

No

If yes, please list the medications, dosage, frequency and purpose:

Have you experienced any hospitalisations or medical treatments related to mental health?

Yes

No

If yes, please describe:

Do you have any physical health issues that may affect your mental health (e.g., chronic pain, illness)?

Yes

No

If yes, please explain:

CURRENT CONCERNS

What brings you to therapy?:

How long have you been experiencing these concerns?

Are there any specific events that have triggered or worsened your concerns?

What coping strategies or actions have you tried so far to address these concerns?

If other, please specify here:

LIFESTYLE AND SUPPORT

Do you have a support system/network in place?

Yes

No

If yes, who is part of your support system?

How do you typically manage stress?

Describe your current sleep habits:

Describe your current eating habits:

How often do you exercise or engage in physical activity?

Do you engage in any mindfulness or relaxation practices (e.g., meditation, yoga)?

Yes

No

If yes, please specify:

THERAPY GOALS

What do you hope to achieve through therapy?

What would success in therapy look like to you?

Is there anything else you would like your therapist to know about you or your situation?

CONSENT AND CONFIDENTIALITY

Do you understand that therapy sessions are confidential, except in cases where there is a risk of harm to yourself or others?

Yes

No

Do you consent to receive therapy services?

Yes

No

Are you prepared to give 100% commitment to yourself and your progress while in therapy with your SLM therapist?

Yes

No