Client Intake Form

Client Intake Form

This form helps me gently prepare for our time together so I can support you in the most meaningful way
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What brings you to support right now?
What would you like to feel different or achieve?
This service is a wellbeing and co-regulation support space. It is not therapy, diagnosis or medical treatment,
I understand this is a wellbeing/co-regulation service and not therapy, diagnosis, or medical treatment.
I understand I am responsible for my own wellbeing and will seek additional support if needed.
I understand my contact details will be used to arrange sessions and share essential information (e.g. scheduling, updates).
I understand confidentiality may be limited if there is a safeguarding concern or risk of harm.
I would like to receive occasional resources, updates, and information about services.
Session Terms: I understand that payment is required at least 24 hours in advance to secure my session. I understand that my session time is held specifically for me. I agree to give at least 24 hours’ notice if I need to reschedule. I understand that missed sessions or late cancellations are non-refundable
Please add you GP name and contact number *this will only be used with your consent, or in case of a safeguarding concern
Details of your next of kin *will only be used in case of emergency
Signature
Should be Empty: