Client Intake

Referred by

Date

First Name*

Surname*

D.O.B.*

E-Mail

Phone Number*

Alternate Number*

Address*

Post Code*

OK to identify the caller?
YesNo

OK to leave a message?
YesNo

First Language

Ethnic/Cultural Identity

Preferred Pronouns
She/her/hersHe/him/hisThey/themOther (Please specify):

Select one
SingleDatingLiving with a partnerMarriedDivorcedWidowedSeparated

Partners name

Partners pronoun

Other Significant Relationships (parents, children, siblings, etc.)

Name

Contact Phone#

Alternative contact#

Permission to contact in case of emergency?

Relationship to you

GP Name

GP Practice and address

Medications (if relevant):

Diagnosed/Suspected Health Conditions (including Mental Health):

Previous Experience with Counselling/Psychotherapy:

Reason for seeking counselling:

How did you hear about this counselling service?

Is there anything else you would like me to know about you or that might be important for us?

Redefine – Metamorphose – Actualise