Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Personal Information Name *FirstLastLayoutDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Contact no. *Gender *SelectMaleFemaleEmail *Address *Emergency Contact: LayoutName *Contact no. *Background information: *NextLayoutOccupation *Marital Status: *SelectMarriedSingleLiving Situation (Alone, with Family, Roommates, etc.): *Briefly describe your current support system: *Referral Information: *NextHow did you hear about my services? *WebsiteReferral (Specify)*Social MediaOther (Specify)*Reasons for Seeking Therapy*SpecifyNextWhat specific issues or challenges bring you to therapy? *AnxietyDepressionSocial AnxietyRelationship IssuesTraumaGrief and LossAddictionOther (Specify)**SpecifyNextPlease briefly describe your current emotional state: *NextHave you received therapy or counselling before? *YesNoPlease provide a brief history *NextMedical and Psychological History: Do you have any medical conditions or take any medication? *YesNoPlease specify: *NextHave you ever been diagnosed with a mental health disorder? *YesNoPlease specify: *NextGoals for Therapy: What are your primary goals for therapy? *Coping with stressImproving relationshipsOvercoming specific fears or phobiasManaging emotionsEnhancing self-esteemOther (Specify)Please specify: *NextIs there anything specific you hope to achieve through therapy?NextAdditional Information: Is there any information about your cultural or religious background that you feel is important for me to know?Are there any specific preferences or concerns you have regarding the therapeutic process?NextConsent and Agreement: I understand that the information shared in therapy is confidential, with certain exceptions. *YesNoI agree to the 24-hour cancellation policy. *YesNoLayoutSignature *(Type your full name as a digital signature)Date: *Submit
