Welcome

1

What is your full name?

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Where did you hear about The Healing Minds Hub?

5

Are you filling out this form for yourself or on the behalf of someone else?

Myself Someone else

6

Is the person your completing this form for currently receiving any 1-1 therapeutic interventions This includes counselling or CBT

YESNO

7

What brings you to The Healing Minds HubThis only needs to be brief, only disclose what you feel comfortable sharing.

8

Are there any specific goals you wish to achieve through Drawing and Talking TherapyIf this doesn’t apply please write n/a

9

Do you understand that the information provided is confidential and will only be used to assess your needs?

YESNO

10

Type a question