Holistic Counselling Intake Form

Holistic Counselling Intake Form

Bianca Azevedo Wellness
Client Information
Name

First NameLast Name
Preferred Name / Pronouns
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name
Relationship to the Client
Emergency Contact Phone Number
Medical & Mental Health Information

Please note: As a Holistic Counsellor, I do not diagnose or treat clinical medical or psychiatric conditions. This information ensures I can support you safely within my scope of practice.
Primary Care Physician / GP Clinic
Physician's Phone Number
Known Medical Conditions
Medications (Please list current medications, including dosage)
Allergies or Sensitivities
Have you ever been diagnosed with a psychiatric or clinical mental health condition? (e.g., Clinical Depression, Bipolar Disorder, PTSD, etc.) - If YES, provide brief details.
Have you experienced past trauma that you feel may impact our work together? (You do not need to provide details here, this just helps me hold the right space for you)
Do you have a history of self-harm, or are you currently experiencing thoughts of suicide? (If yes, please contact Lifeline at 13 11 14 or emergency services at 000 immediately)

Holistic Wellness, History & Goals
Have you received holistic wellness services or counselling in the past? If yes, please provide details:
Are you currently receiving any other forms of therapy or treatment? If yes, please specify:
What inspired you to seek holistic wellness services at this specific time?
What specific goals or areas of your well-being would you like to address through our work together?
Are there any specific areas of your life where you feel stuck in "survival mode" and would like to find more balance and clarity?

Terms & Conditions Consent
Signature
Package Expiration & Booking Policy
- 3-Session Packages expire 2 months (8 weeks) from purchase.
- 5-Session Packages expire 3 months (12 weeks) from purchase.
Sessions must be scheduled within these windows to protect therapeutic progress. Payments are non-refundable.
Select Your Session Option:
Bianca da Silva Azevedo

BSB 062-009

Account 1107 9983
Please transfer the corresponding amount for your chosen package and upload your receipt below.

Cancelof
Should be Empty:

Client Information