I need help

Online Intake Form

If you are need of assistance, please complete and submit the form below. It asks specific questions in an effort to better understand who you are and what it is you hope to achieve out of the sessions.

All the information pertained in the form is encrypted prior to submission.

Part — 1

PARTICULARS OF APPLICANT (1 OF 2)

First name

Last name

Contact Number

Email address

Age

Birthdate

Passport / ID Number

Occupation

PARTICULARS OF APPLICANT (2 OF 2)

Part — 2

EMERGENCY CONTACT DETAILS

Full name

Contact number

Email address

Relationship

Part — 4

PLEASE PROVIDE ANSWERS TO THE FOLLOWING QUESTIONS

Have you ever been treated by a therapist/counsellor before? If so, when and for what?

Are you currently being treated by a therapist/counsellor?

Are you currently on any medication? If yes, please list your medication

How often do you drink alcohol?

How often do you do recreational drugs?

Have you ever been hospitalised for drug abuse or alcohol abuse, suicide attempts, or other mental health concerns? If so, please give the approximate dates and circumstances

What is your overall health like?

Do you have any medical problems now or in the past that would be helpful for me to know about?

It would be helpful to know about your family of origin, what your childhood was like, and anything else about what your family and life like growing up

Have you ever felt in the past like harming yourself or someone else?

Do you have those feelings now?

Is there anything else about you I should know such as ethnicity, gender preference, or sexual identity?

How many hours a day do you spend on your model device/computer?

Do you have any other concerns about finding balance in your life with issues such as exercising, gambling, sexual activity, food, etc.?

If you have a partner, how long have you been together?

If you have children, please give their names and ages

Who lives with you?

What is your highest level of education?

Reasons for the referral / motivation for therapy

What are you hoping to achieve in therapy?

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I need help

Online Intake Form

Part — 1

PARTICULARS OF APPLICANT (1 OF 2)

PARTICULARS OF APPLICANT (2 OF 2)

Part — 2

EMERGENCY CONTACT DETAILS

Part — 3

WHICH OF THE FOLLOWING DO YOU HAVE EXPERIENCE WITH

Part — 4

PLEASE PROVIDE ANSWERS TO THE FOLLOWING QUESTIONS

The curious paradox is that when I accept myself just as I am, then I can change.

—Carl Rogers

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