Client Intake Form

WELCOME TO THE START OF YOUR 1-2-1 SESSIONS WITH ME Pre Session Questionnaire

Complete the form before our initial session. If the questions feel too triggering, please just fill in your personal details.
Name

First NameLast Name
Date

MonthDayYear
Date
E-mail
Phone Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date:

MonthDayYear
Emergency Contact Details
YESNO
If yes, please give details and of any diagnosed conditions as well.
Briefly describe the reason you have booked your sessions with me?
Briefly describe your relationship between you and your parents growing up.
Briefly describe your relationship with any extended family.
Briefly describe your relationships with friends growing up.
Briefly describe your relationship with any romantic partners growing up.
Briefly describe any previous relationships you have had and the outcomes.
Briefly describe your relationship with your current partner if you have one or your ex partner?
What would you say are your top 3 immediate struggles?
If I could wave a magic wand, how would you like to feel when our sessions have finished?
What is your main focus in our sessions?
Why do you think you are not where you want to be?
What have you tried before to help yourself on this subject?
Anything else you feel relevant that could be part of why you are where you are today?
On a Scale of 1–10 How committed are you to your personal change? (10 is absolutely and I am 100% ready, 1 is not at all)
Thank you for filling in the questionnaire and look forward to our first session. Do not hesitate to reach out f you need anything before our session
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WELCOME TO THE START OF YOUR 1-2-1 SESSIONS WITH ME Pre Session Questionnaire

Thank you for filling in the questionnaire and look forward to our first session. Do not hesitate to reach out f you need anything before our session