New Client Intake Form Name * First Name Last Name Email * Are you filling out this form on behalf of someone else? Full Name and Date of Birth Home Address What are the concerns you are seeking help with? How have these concerns been impacting your life? For how long? Are there any concerns about self-harm, suicide or substance abuse? Have you ever received a mental health diagnosis? Are you currently involved in any court proceedings? Have you been referred by a GP? Name of doctor Are you seeking a specific type of treatment? e.g. CBT, EMDR How did you hear about us? What days of the week are most suitable? Monday Tuesday Wednesday Thursday Friday What time of day is the most suitable? Mornings (9am-12pm) Afternoons (12pm-4pm) Evenings (4pm-6pm) After school Types of appointments preferred In-person Telehealth In-person or Telehealth Thank you! A member of our team will contact you within one business day.
