Thank you for booking a consulation

Please complete this questionnaire to the best of your ability prior to our consultation. Kindly include only the information you feel is important and are comfortable sharing, as there is a possibility we may not proceed with working together.

Name

First Name

Last Name

Phone

(###)

###

####

What services are you interested in?

Mental Health Counseling/Psychotherapy

Health Counseling

What brings you to therapy?

Please briefly describe the main challenges or issues you're currently facing (e.g., anxiety, depression, relationship difficulties, life transitions):

What are your goals for therapy?

What would you like to achieve through therapy (e.g., symptom relief, coping strategies, personal growth)?

Have you been in therapy before?

Yes

If yes, how was your experience?

Briefly describe your current life circumstances.

Please include any major stressors, work or family dynamics, or significant life changes.

Do you have a support system?

Please describe any personal support (e.g., friends, family, community) that you have.

Are there any immediate safety concerns?

(e.g., thoughts of self-harm, harm to others, or current abuse). If yes, please briefly explain:

What are you looking for in a therapist?

Please describe any preferences regarding the therapist's approach or style.

Are there any logistical details you’d like to share?

(e.g., availability, scheduling, financial considerations)

Checkbox

How comfortable do you feel with the idea of starting therapy?

Very comfortable

Somewhat comfortable

Unsure

Not comfortable

Is there anything else you would like me to know?