Intake Form

Privacy Statement

Any information provided by a client via this online form WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within three business days.

Today's Date:    
First Name: Last Name:
D.O.B. Age:
Nickname (if any): Gender:
Address Line 1: Address Line 2:
Town/City: County/State:
Postcode: Country:

Home Phone: Other Phone:
Email Address: Please be aware that if you are using your work email, your employer does have the right to access your email account and could read your emails.
What experience do you have with email? I check my inbox:




What platform is your computer on? Other:
What type of Internet access do you have?



Do you use anti-virus and spyware programs? Please specify.
In Case of Emergency
Who should be contacted? Relationship to client:
Home phone no. Work phone no.
Intake/Background Information
Have you ever been in treatment with a therapist or counsellor in the past?



If so, when were you treated and for what problems?
What was the result of this treatment? Are you being treated by a therapist, psychotherapist or counsellor now?



Are you experiencing any 'negative' feelings or 'symptoms' at this time, eg: feeling anxious, depressed, sad, angry, frustrated etc?



How serious would you say these feeling are?




What have you already tried for this problem? Have you tried anything else that did help?



If 'Yes' what DID help? Are you currently taking any psychotropic medication (eg. anti- depressants or anxiety medication)?



Have you taken any psychotropic medication in the past?



Please list all medications you are now taking, including dosage. Please include prescription, over-the-counter, herbal, homeopathic medications and nutritional supplements
How often do you drink alcoholic beverages?






How often do you use recreational drugs?






Have you ever been hospitalised for drug or alcohol abuse, a suicide attempt, 'nerves' or other mental health concern?



If 'Yes' please give dates and circumstances
If you are married or have a 'significant other' or long-term partner, how long have you been together? Please describe your relationship
If you have any children please list their names and ages
Who lives in the household with you?  
Do you have any brothers or sisters?






Where do your siblings live and how do you get along with them?
Are your parents alive?
How do you get along with them?
Do you have in-laws?
How do you get along with them?
How much education have you completed?





If 'Other' please state:
If you are a student now, please complete the following 2 questions
Which school do you attend, how are your grades and how do you like school? If you are in college or university, what subject(s) are you studying?
Are you happy with your current job/career?



If not, why?
What jobs have you done in the past and how did you like them? How many times have you moved jobs in the past year?






Have you ever been arrested or convicted of a crime?



If 'Yes' please explain
It would be helpful to know about your family or origin, what your childhood was like, and anything else about what your family and life were like when you were growing up (If your past history includes abuse of any type please include this)
Were you ever physically or sexually abused as a child?



If so, by whom?
Are you being physically or sexually abused now?



If so, by whom?
Have you ever felt in the past like harming yourself or somebody else?



Do you have those feelings now?



Have you ever harmed yourself?



Is there anything else I should know?

Agreement

I have read and completed this form truthfully and accurately to the best of my knowledge .

I have also read Geoff T Cox's Informed Consent document.

Please confirm to continue.

Please click on Submit Form button below to submit this information. It will be sent in encrypted form to ecounselling@hush.com