Client Intake Form

Client Intake Form
SECTION 1: Personal and Contact Information
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Place of Residence

CityState / Province

Postal / Zip CodeCountry
Section 2: A Little More About You
Are you currently taking any medication?
If yes, please list any medication you are currently taking:
Have you ever experienced thoughts of suicide or self-harm, or engaged in any form of self-injurious behaviour? If so, please feel free to share anything you feel would be helpful for me to know.
SECTION 5: Emergency Contact
Emergency Contact Name
Emergency Contact Phone Number (Please include country code)
Their relationship to you (e.g., friend, sibling, partner)
SECTION 6: Consent & Privacy

Please read the following carefully before submitting
About your data

Your privacy is something I take very seriously. Here is how your information is handled:

• The information you share in this form is collected solely for the purpose of us working together therapeutically
• Your data is stored securely and is not shared with any third party without your explicit consent, except where I am legally or ethically required to do so.
• If you are based in the EU or UK, your data is handled in accordance with GDPR principles
By submitting this form, I confirm that:
Should be Empty:

Section 2: A Little More About You