Intake form Name * Email * Phone * (###) ### #### Address Name, Address and Relationship of your Emergency Contact How did you hear about us? Google Recommendation Other What is the primary reason for seeking counselling? * What do you hope for/expect from counselling? Is there anything in particular you would like me to know? Behaviour Tick the ones that apply to you Eating problems Suicidal attempts Can’t keep a job Taking drugs Compulsive behaviour Insomnia Vomiting Taking risks Lack of motivation Drinking too much Withdrawal Procrastination Sleep disturbance Crying Aggressive behaviour Poor concentration Impulsive reactions Work too hard Avoidance Loss of control Other Feelings Tick the ones that apply to you Angry Guilty Sad Jealous Lonely Hopeless Tense Anxious Miserable Bored Relaxed Fearful Annoyed Helpless Panicky Frustrated Regretful Unhappy Conflicted Worthless Other Physcial Tick the ones that apply to you Headaches Dry mouth Skin problems Palpitations Chest pain Tremors Numbness Stomach pain Unable to relax Tingling Twitches Sexual disturbances Fatigue Fainting spells Excessive sweating Other Thank you for reaching out to us. We’ll be in touch with you shortly.
