Intake form

Name *

Email address *

What is your date of birth?

What are your preferred pronouns?

Please select at least one option.

He/Him

She/Her

They/Them

What is your primary reason for seeking therapy?

Please select at least one option.

Anxiety

Depression

Stress Management

Relationship Issues

Trauma

Self-Improvement

Have you previously attended therapy?

If yes, please provide details about your previous therapy experience.

Are you currently taking any medication related to mental health?

If yes, please specify the medication(s).

What is your preferred method of communication?

Please select at least one option.

In-person

Video Call

Phone Call

Email

Do you have any specific goals you would like to achieve through therapy?

How did you hear about us?

Please select at least one option.

Referral

Search Engine

Social Media

What is your availability for therapy sessions?

Please select at least one option.

Weekdays Morning

Weekdays Afternoon

Weekdays Evening

Weekends

Which service or services are you interested in?

Please select at least one option.

Terapia indywidualna

Terapia grupowa

Terapia par

Pierwsza konsultacja

Konsultacja do grupy

Psychoterapia rodzin

Additional questions or comments

Powiązania