Counselling Client Intake Form
Personal Information
Full Name
Date of Birth
Gender
Ethnicity
Home Address
Email Address
Phone Number
Emergency Contact Name
Emergency Contact Phone Number
Employment Details
Employment Status
Occupation/Job Title
Is the client able to continue working normally?
Yes
No
Referral Information
How did you hear about this counselling service?
Friend/Family
Doctor
Website
Other
Reason for Counselling
What brings you to counselling at this time?
What are your goals for counselling?
Mental Healthy History
Have you previously seen a counsellor or therapist?
Yes
No
If yes, please describe
Are you currently taking any medications for mental health?
Yes
No
If yes, please list
Have you ever been diagnosed with any mental health conditions?
Yes
No
If yes, please specify
Physical Health
Do you have any chronic health conditions?
Yes
No
If yes, please specify
Safety and Risk Assessment
Have you had thoughts of harming yourself or others recently?
Yes
No
If yes, please explain
Do you currently feel safe in your home and relationships?
Yes
No
If no, please explain
Additional Information
Is there anything else you think I should know?
Did you read the Cancellation & Missed Appointment Policy?
Yes
Client Consent
I understand that counselling is a confidential process, except where disclosure is required by law or for safety reasons. I consent to participate in counselling sessions.
Yes I Consent