Client Intake Form

  • Client Intake Form

  • Thank you for reaching out. This form will help me understand what brings you here and how we might work together. It should take no more than 5–10 minutes to complete. All information you share is kept strictly confidential and stored securely.

  • SECTION 1: About You

  • Date of Birth *
     / /
  • Format: (000) 000-0000.

  • SECTION 2: What Brings You Here

  • What has brought you to seek support at this time? There are no right or wrong answers here, share as much or as little as you feel comfortable with. 

     

  • Have you been in therapy before? *
  • Are you currently seeing any other mental health professional? *

  • SECTION 3: A Little More About Your Wellbeing

  • Are you currently taking any medication?*

  • SECTION 4: Practical Details

  • Which days are you generally available for sessions? (Please select all that apply)*

  • SECTION 5: Emergency Contact

    This is a standard part of my safeguarding practice. This person would only ever be contacted in situation where there was a serious concern for your or someone else's safety

  • 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:

  • Once I receive your form, I will be in touch to arrange an initial consultation.

    I look forward to connecting with you!


    Warm regards, 

    Saba 

    (sabamarikarpsyp@outlook.com)

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