Therapy Intake

Your name (required)Date of birth (required)Email address (required)Phone number (required)AddressEmergency contact - name, relationship and number (required)Your doctor's practice

What's happening

In your own words, what's going on? (required)How long has this been going on? (required)What have you already tried? (required)What would you like to be different? (required)

History and health

Have you had therapy before? (required)What was helpful or unhelpful about it?Any medication, including for physical healthPhysical health conditionsDo you use alcohol or other substances to cope? (required)How are you sleeping? (required)

Safety

These questions change how quickly we respond and what support we suggest - not whether we can help. Please answer honestly.

Have you harmed yourself in the last month? (required)Have you had thoughts of ending your life? (required)Do you have people around you? (required)Anything else you'd like me to know before we meet?