Intake Form

* Indicates required field

First Name *

Last Name *

Address *

Suburb *

State *

Post Code *

Phone Number *

Email *

Date of Birth *

Gender *

Marital Status *

Occupation *

Referred by/ Where did you find me? *

Are you currently receiving medical or psychological treatment? If so please provide details *

Please list any prescription medication you are taking (including dosage) *

Have you ever been diagnosed with a mental illness? If so please provide details including medication prescribed *

Please provide details of any prior illnesses or medical conditions *

What's happening for you? / Why are you coming for this session? (Please describe in detail what's happening for you and how it is affecting either an area of your life or your whole life) *

Please provide any relevant information regarding current or past trauma, relationship or family issues *

When do you feel happiest/ most alive/ thriving? *

Do you have any particular fears/phobias? *

How do you relax? How often do you relax? *

How often do you exercise and what exercise do you do? *

Is there anything else you would like me to know? *

Important: Your session/s are not intended as a substitute for medical or psychological diagnosis or treatment, and advice from a qualified medical practitioner is always recommended. Do not stop any treatment that you are currently receiving without the prior consent of your practitioner.

I confirm that I have read and understood the information provided. By entering my name in the box below, I acknowledge that it serves as my signature for this Intake Form and will be treated as such.

Select 'Yes' or tick to confirm *

Yes

Signature *

Date *

Parent/Guardian signature for minors *

Disclaimer: This information is collected and stored for the purpose of your treatment. Your information is confidential and will not be shared or used for any other purpose without your consent.

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