New Client pre-session info
All information will be treated with the highest sensitivity and kept fully confidential.
Welcome.
Thank you for reaching out. Please take a few moments to kindly complete this short pre-screening form. The information you share will help me, as your potential therapist, to assess whether I’m the right fit for supporting your journey and will provide essential insights for a successful start to our work together. Rest assured, the information you provide will be treated with the highest sensitivity and kept fully confidential. Feel free to fill out as much as you’re comfortable with - your responses will guide our first steps and help us build a safe, informed foundation. Warmly, Olja.
Full Name
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First Name
Last Name
What is your age?
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What is your gender?
*
Please Select
Male
Female
N/A
Contact Number
*
Email Address
*
example@example.com
What brought you to seek therapy or psychological consultation, and how did you find about me?
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What are the main challenges or topics you’d like to work on in therapy?
Do you have any current mental health diagnoses (e.g., depression, anxiety, bipolar disorder)?
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No
Yes
Please specify if applicable.
Are you currently taking any prescribed medications related to mental health?
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No
Yes
If so, please list them and the purpose for each.
Do you have any health issues, such as heart conditions, asthma, epilepsy, etc., that I should be aware of for our work together?
No
Yes
Please specify if applicable.
How would you describe your current emotional and physical well-being?
Are there specific goals you want to achieve through our work together?
Have you previously worked with a therapist or psychiatrist?
No
Yes
Please specify if applicable. E.g. What kind of therapy you tried? What aspects of the experience did you find most helpful or challenging?
Have you used any drugs/substances (including both natural or synthetic derivates) in past year?
Please Select
Yes
No
What kind and how long have you used/been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Client Statement and Agreement: By submitting this form, I confirm that the information provided is accurate to the best of my knowledge and given voluntarily to assist in the pre-screening process. I understand that this information will be used solely by addressed psychologist for evaluation purposes to determine the suitability of therapeutic services. I acknowledge that all information will be kept confidential in accordance with professional ethical standards.
*
Please Select
YES
Submit
Should be Empty: