Therapy Intake Form

The information you provide will be kept confidential and used only to support your individual therapy process. It will not be shared without your consent, except as required by law.

Therapy Intake Form

Your Full Name Required

Your Age Required

Your Gender

Male Female

Your Phone Number Required

Where do you live? Required

Your Email Address Required

Emergency Contact — Next of Kin Name and phone number Required

Background Information

Your Occupation / Profession

Marital Status

Do you have any previous experience with therapy (individual or group counselling)?

Yes No

Required

Reason for Seeking Therapy

Please briefly describe the main reason(s) you are seeking therapy Required

Goal of Therapy

What would you like to gain from participating in therapy? Required

Medical / Mental Health History

Do you have any current medical conditions or mental health diagnoses we should be aware of?

Yes No I don't know Not Sure

Required

If yes, please specify

Consent & Preferences

I consent to participate in the therapy session and it is willful and not forced Required

How would you like to do the therapy sessions?

Physical Online

Required

Your responses are encrypted in transit and only shared with Faith Njogu.