Booking and Therapy Intake Form

Section 1

Section 2

Therapy Intake Form - Confidential

Therapy Intake Form - Confidential

To be completed by the client without influence. Please complete the information on this form. These are some of the questions we might ask you during your first session in order to help you achieve your goals better. Completing this form accurately helps reduce the time spent on these questions during your session, so we can focus on other areas. It may seem long, but most of the questions require only a check, so it will go quickly. If you have any questions, please send us a WhatsApp message on 08096642604 and we would respond ASAP.

Please write in details to enable us to have an idea of how to help you efficiently
Please write in details to enable us to have an idea of how to help you efficiently
Please write in details to enable us to have an idea of how to help you efficiently
Current Symptoms Checklist (Please check all that applies to you) *
How would you classify your eating habit? *
How would you classify your sleep? *
Have you ever had feelings or thoughts that you didn't want to live? *
If YES or MAYBE to the question above, please answer the remaining 11 questions on this section. If NO, please skip to the next section (skip the next 11 questions).
Do you currently feel hopeless and/or worthless?
Do you currently feel that you don't want to live?
How often do you have these thoughts?
Have you ever had the thought to kill or harm someone else? *
Have you ever had an outpatient treatment? *
Have you ever had a psychiatric hospitalization? *
Past/ Present Psychiatric Medications (check all that applies)
Has anyone in your family (immediate or extended) been diagnosed with or treated for (check all that applies)
Do you exercise regularly? *
Have you ever been treated for alcohol, drug use? *
Check if you have ever tried any the following (check all that applies)
Have people annoyed you by criticizing your drinking or drug use?
Have you ever felt you ought to cut down on your drinking or drug use?
Have you ever felt bad or guilty about your drinking or drug use?
How much time did you spend with your immediate family when growing up? *
Did your parents' divorce or seperate? *
Has anyone in your immediate family died? *
Check any of the following that applied during your childhood/adolescence *
Do you have ANY traumatic experiences? *
How would you grade your overall performance? *
How would you grade your performance in primary school? *
How would you grade your performance in secondary school? *
Were you bullied at any time in school? *
Did you bully anyone at any time in school? *
Are you currently *
Are you currently *
Do you have children? *
Do you have any pending legal problems? *
Do you have any pending debt problems? *
Do you belong to a particular religion or spiritual group? *
Do you find your involvement helpful during this trying period, or does the involvement make things more difficult or stressful for you? *
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