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THERAPY INTAKE FORM

Fill In Your Info

Name

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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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