• Psychotherapy Client Intake Questionnaire

    Please fill in the information below and bring it with you to your first session.                              Please note: information provided on this form is protected as confidential information.
  • Personal Information

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  • *Please note: Email correspondence is not considered to be confidential medium of communication.

  • History

  • General and Mental Health Information

  • Family Mental Health History

  • In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

  • Additional Information

  • Should be Empty: