Colorful Minds - Intake Form

Colorful Minds - Intake Form

Thank you for making me a part of your therapy journey. Please fill in the form below to allow me to get to know you better before we begin sessions. All information shared by you will be kept completely confidential and safe. Note: All online sessions will be video calls which are conducted on Google Meet, if you have a specific request, it will be considered. In-Person sessions can be accommodated separately.
Client Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.
WhatsApp Number*
Please enter a valid phone number.
Date of Birth*
Gender*

FemaleMaleOther
Relationship Status*

SingleIn a RelationshipMarriedDomestic PartnershipWidowedSeparated / Divorced
Are you currently in a relationship, married or in a divorce process? If so, please provide your partner’s name. This helps avoid ethical conflicts if both parties seek therapy separately. If not, mark it as N/A*
Employment Status*

Full-timePart-timeUnemployedStudentOther
Language Preference*

EnglishSinhala

Mental Health History
What are your current reasons for seeking therapy?*
Please mention all concerns related to personal, professional, social, relationship, health or other for which you are seeking help.
Have you consulted a counsellor, psychologist or therapist before?*

YesNo
Have you consulted a psychiatrist before?*

YesNo
Is there any mental health history in the family?*

YesNo
Please list any psychiatric or mental health issues you have been diagnosed with / any medication you have been prescribed or is currently using. If not applicable mark N/A:*

How did you hear about me?*

Social Media (Instagram)Social Media (Facebook)Website (colorfulmindscm.com)Mental Health DirectorySearch Engines (Google etc.)ReferralOther
If you were referred by someone, please specify their details

First NameLast Name
Should be Empty: