• Please Complete This Intake Form

  • Personal details

  • Employment status*
  • Format: (000) 000-0000.

  • Family details

  • Marital status*

  • Counselling / Personal therapy history

  • Have you attended therapy before?*

  • Medical history

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How often do you consume alcohol?*
  • How often do you consume drugs?*

  • Please Sign The Form Below

  • By signing this form, you acknowledge that you understand and agree to participate in counselling services provided by Klaudia Kovacs. You understand that:

    Your participation is voluntary and you may withdraw at any time.
    Sessions are confidential, except in circumstances where disclosure is required by law (e.g., risk of harm to self or others, child protection concerns).
    Your personal information will be handled in accordance with the Global Data Protection Regulation and it will not be shared with third party agents unless officially required by law. 

     

     

     

  • Consent*
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