Metapsychotherapy Individual Intake Form

Individual Information Form

Please fill in the fields carefully.
Metapsychotherapy is dedicated to handling personal information in compliance with the EU's General Data Protection Regulation (GDPR), and the Australian Privacy Act of 1988.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender
What are your preferred pronouns?
Relationship Status

Never MarriedMarriedSeparatedWidowedDivorcedPoly RelationshipOther
Email*
Number*

Country CodeArea CodePhone Number
Is it okay to e-mail you?*

YesNo
Is it okay to leave you messages?*

YesNo
Current Occupational Status

Full TimeSelf EmployedPart TimeStudentOther
How were you referred to us?
What are your reasons for seeking therapy at this time?
What do you hope therapy will help you resolve?
The following information will guide us to better understand you in a comprehensive, systemic way. Some of these questions may be difficult, challenging, or triggering to answer.
Relationship Background
How many relationships have you had prior to this one? How long were they? How did they end?
Do you have children (biological, stepchildren, adopted)?
If yes, please give their ages and a brief description.
Have you had a child die?
If yes, please include how, and their ages.
Family Background
Were your parents married? Did they get divorced? Are there any other important details about their relationship?
Were you adopted?
If yes, at what age? Do you know your birth parents?
Do you have any siblings?
If yes, how many? What are their ages and birth order?
Have any of your parents or siblings died?
If yes, please indicate name, cause, and date of death.
History
Have you had previous personal development or counseling?
If yes, please indicate from whom, for what, and its effects.
Have you attempted suicide or had suicidal thoughts?
If yes, at what age? Please provide the name of your current physician.
Please list any medications, herbal, or homeopathic treatments you are taking and the conditions they are meant to treat.
The following information will guide us to better understand your current personal wellbeing.
Current Experiences

Check any of the following boxes that apply to you currently.
I am currently experiencing the following behaviours.

DepressionImpulsive ReactionsSexual ProblemsLostTaking Too Many RisksUnable to FocusArgumentsNot Getting My WayLacking EnjoymentOutbursts of TemperProcrastinationLack of PurposeAggressive BehavioursWorking Too HardAvoiding My PartnerRelationship BreakupsSubstance AbuseEating ProblemsOther
I am currently experiencing the following feelings.

AngryConflictedContentedEnergeticContemptuousDepressedFearfulRelaxedGuiltyHopefulTenseAnnoyedRegretfulHappyLonelyJealousExcitedHelplessSadPanickyHopelessBoredRestlessUnhappyEnviousAnxiousOptimisticConfusedStuckManicDisgustedNumbOther
I am currently experiencing the following physical symptoms

HeadachesVisual DisturbancesUnable to RelaxBack PainDry MouthStomach ProblemsExcessive SweatingFainting SpellsTwitchesPalpitationsFlushingTinglingSexual DisturbancesChest PainsDizzinessFatigueMuscle SpasmsTremorsBumpy or Itchy SkinHearing ProblemsBowel DisturbancesRapid HeartbeatTicsHearing ThingsWatery EyesBlackoutsAversion to TouchTensionNumbnessSkin ProblemsOther
Thank you for sharing this information, especially the difficult or challenging parts. All information will be handled as per our Privacy Policy
MetaPsychotherapy PTY LTD

ACN 666 077 185 ABN 40 666 077 185
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Individual Information Form

Relationship Background

Family Background

History

Current Experiences