Victoria Jane Therapy Intake Form

Personal Details
Full Name

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Occupation
Telephone
Please enter a valid phone number.
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship Status
Health Information
Doctor's Name
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Last Check-Up

MonthDayYear
Medications Being Taken
Health Problems (past & current)
From the list below tick your areas of concern:
AddictionsDrinkingSmokingDrugsGamblingCompulsive BehaviourAnxiety StressFearsPhobiasPanic AttacksGuiltRelaxationEating ProblemsFood/DietWeight ProblemsAnorexiaBulimia ExerciseDepressionConfidenceSelf EsteemMotivationAchieving GoalsProcrastinationCareer IssuesInterview SkillsNervesPublic SpeakingConcentrationExamsMemoryDriving SkillsSexual ProblemsFertilityIVFConception PregnancyBirth Pain ControlHearingSight/VisionMobilitySkin ProblemsHair GrowthRelationshipsChildhood ProblemsSleep Problems
From all of the above, please state which has the highest importance to your life right now
In what situations would this issue affect you the most?
If you had to say where in your body the effects of this issue is, where do you feel it the most?
In our session we will talk about your childhood circumstances and relationships with other family members. Please give some thought to to this from when you were born to now.

I will ask you what results you want from this session and going forward. I would also like you to think of how your life would look for you without this issue. How would your day start? What are the benefits in removing the problem for you> What prospects will be available to you once the issue has gone?

Please take the time to fill in the form below. For therapy to do it's best, you as the client must be 100% committed to answer as best you can and follow the instructions given. It is also important that if you feel the need to discuss any issues arising from the session, you message me with a brief outline of the issue you're having and I can call you back and continue to support you during the 21 days following the session while you are listening to the recording daily.
Should be Empty:

Personal Details

Health Information

From the list below tick your areas of concern: