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THERAPY INTAKE FORM

Fill In Your Info

Name

Thanks for submitting!

Birth Date

Age

Gender

Marital Status

Never Married

Partnered

Married

Separated

Divorced

Widowed

Number of Children

Local Address

Home Phone

May we leave a message?

Yes

Mobile/Other Phone:

Can we text you?

Yes

May we email you?

Yes

Emergency contact details

Are you currently receiving psychiatric services, professional counselling or psychotherapy elsewhere?

Yes

Have you had previous psychotherapy?

Yes

Are you currently taking prescribed psychiatric medication (antidepressants or others)?

Yes

If Yes, please list

If not, have you been previously prescribed psychiatric medication?

Yes

Please list, if Yes

Fill In Your Info

Name*

Date of Birth*

Gender*

Marital Status*

Never Married

Partnered

Married

Separated

Divorced

Widowed

Number of Children*

Local Address*

Home Phone

Mobile/Other Phone*

Can we text you?*

Yes

Email*

Please be aware that email might not be confidential.

May we email you?*

Yes

Emergency contact details*

Are you currently receiving psychiatric services, professional counselling or psychotherapy elsewhere?*

Yes

Have you had previous psychotherapy?*

Yes

Are you currently taking prescribed psychiatric medication (antidepressants or others)?*

Yes

Renata Webster | Counsellor | Brisbane, Australia

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Intake Form

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