Client Intake Form

As part of our duty of care, all clients are required to complete an intake form before their first session. The information you provide helps us understand your needs and ensure your safety during your therapy journey with us.

First name

Last name

Preferred name

Email

Phone

Birthday

Month

Day

Year

Ethnicity

Gender

Pronouns

Home/Residence Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

GP Practice Name

GP Name

GP Address & Postcode

GP Contact Number

Next of Kin Name

Next of Kin Relationship

Next of Kin Contact Number

Health & Medications

Client Intake Form