5 minutes to complete
To be eligible to complete the Therapy Intake Form, you must be seeking mental health services, be willing to provide personal information, have a genuine interest in improving your mental well-being, and be committed to attending therapy sessions regularly. You must also be over the age of 18 or have parental consent if under 18.
Contact Details
What are your primary reasons for seeking therapy at this time?
How long have you been experiencing the concerns that brought you here?
Have you attended therapy or counseling before? If yes, when and for what concerns?
Are you currently taking any medications? If yes, please specify.
Do you have any medical conditions or allergies we should be aware of?
Please describe any major life changes or stressful events in the past year.
What are your main sources of support (family, friends, community, etc.)?
Do you have a history of substance use (alcohol, drugs, etc.)? If yes, please explain.
How are you currently feeling emotionally? (Sad, anxious, angry, ok, etc.)
Have you ever had thoughts of self-harm or suicide? If yes, please explain.
What are your goals and expectations for therapy?
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