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.Format: (000) 000-0000.
WhatsApp Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth
Gender
Relationship Status
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

Other
Language Preference
- Name
  
  PrefixFirst NameLast Name
- WhatsApp Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Relationship
  eg: partner, sister etc.
- 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?
- Have you consulted a psychiatrist before?
- Is there any mental health history in the family?
- 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:
- Please check all that apply
- Please state any family medical history if present from the above
  eg: father - diabetes
- Please specify your tobacco use
- Please specify your alcohol use
- How did you hear about me?
  
  Other
- If you were referred by someone, please specify their details
  
  First NameLast Name
- Should be Empty: