Individual Counselling

Barefoot Vibes: Counselling Intake Form

Please complete this form prior to your first counselling session. Your answers will help the counsellor understand why you are seeking support and what you you are needing from these session. All responses are confidential.

Full name*

Gender/pronouns (optional)

Contact number*

Email*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact*

First NameLast Name

Emergency Contact*

Please enter a valid phone number.

Occupation & current work load

Are you married, de facto, engaged or other?

Do you have children? Yes/No If yes how many and ages?

Have you had any major stresses in the past 12months?

What do you feel are the main challenges for you currently?

How do you usually handle challenging times?

On a scale of 1-10, how would you rate your current satisfaction with life in general?

1 = very dissatisfied, 10 = very satisfied

What do you see as your strengths?

What are your goals for counselling?

Are you open to making lifestyle changes?

YesNo

Are there any cultural, religious or personal values you would like me to be aware of?

Do you have any preferences for session times, day, evening, weekend?

30. Do you agree to attend counselling in good faith, being respectful and open during sessions?

YesNo

31. Are you open to do homework, reflection, or practice strategies between sessions?

YesNo