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Client Information

First Name *

First

Last

Email *

Contact Number *

Gender

• Female
• Male

What is your age range *

• 18 - 25 Years
• 26 - 35 Years
• 36 - 45 Years
• 46 - 55 Years
• 56+ Years

Session Details

Date / Time

Date

Time

Session Type

• Group
• Individual

Session Length

• 90 Minutes
• 60 Minutes
• 30 Minutes

Why do you think you need therapy?

Emergency Contact Information

Name

Relationship to Client

Phone Number

Additional Information

Have you had any previous experience with therapy or counselling?

• No
• Yes

What gender would you prefer your therapist to be?

• Female
• Male

Please state your preferred language

Consent *

• By submitting this form, I acknowledge that the information provided is accurate and consent to the use of my personal data for the purpose of scheduling therapy sessions for mental health support.

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