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intake form

Please know that I take confidentiality seriously, and the information you provide will not be shared with any third parties without your consent.

Full Name

Preferred Name

Pronouns

Date of Birth (dd/mm/yy)

Phone

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

Emergency Contact Phone

Living situation

Please describe your current living arrangements

Marital Status

Are you currently in a relationship?

Employment Status

Are you currently working or study?

Mental Health History

Including any prior diagnoses and/or medications

Prior Experience in Therapy

Are you currently experiencing overwhelming stress, anxiety, grief, sadness or depression?

If so, please specify approximately how long you have been feeling this way

Have you been having any thoughts of harming yourself or taking your own life?

What would you like to work on in therapy?

Which of these interest you?

Traditional "Talk" Psychotherapy

Expressive Arts Therapy

Dreamwork

Tarot in Psychotherapy

Is there anything else you would like me to know?