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Counseling Intake

A few questions before we speak. Answer as much or as little as you want to. If you are in crisis, please contact your doctor or emergency services.

Your name* (required)Date of birthEmail address* (required)Phone numberHow should we contact you?* (required)Is it safe to leave a voicemail?* (required)

What's bringing you here

What would you like help with?* (required)

Anxiety Depression or low mood Stress or burnout Relationships Bereavement Trauma Anger Self-esteem Work difficulties Life transition Something I'd rather explain in person

In your own words, what's going on?* (required)How long has this been going on?* (required)What would be different if this went well?

Your history

Have you had counselling or therapy before?* (required)Are you taking any medication for your mental health?* (required)Does your doctor know how you're feeling?* (required)Any physical health conditions we should know about?

Support and safety

We ask the next questions because they change how quickly we respond, not whether we'll help. Please answer honestly - nothing here will shock us.

Have you harmed yourself, or thought about it, in the last month?* (required)Have you had thoughts of ending your life?* (required)Who supports you day to day?Someone we could contact in an emergency

Practicalities

How would you like to meet?* (required)

When could you come?* (required)

Weekday morning Weekday lunchtime Weekday afternoon Weekday evening Weekend

Any preference about who you see?

Leave this field empty