General Information

    First Name in English

    Surname in English





    If this intake form is for an individual below the age of 18 years old, please fill the following information by a Parent or Guardian

    Parent/Guardian First Name in English:

    Parent/Guardian Surname in English:

    Parent/Guardian Mobile Number:

    Parent/Guardian Email Address:

    Relationship Status:

    Education Level

    Previous Mental Health Support

    Have you previously received any type of mental health services (counselling, clinical psychology, psychiatric services, etc)?:

    If yes, please indicate if you received any diagnosis:

    Are you taking any psychiatric medication?

    If yes, please list the psychiatric medication(s) you are currently taking (medication name, dosage, frequency, prescribing doctor) :

    General Health

    How would you rate your current physical health?

    How would you rate your current sleeping habits?

    How would you rate your appetite during the past two weeks?

    Have you experienced overwhelming feelings of sadness or grief in the last two weeks?

    Did you experience any significant life changes or stressful events recently?

    If yes, please describe the changes or stressful event briefly

    Do you have any religious affiliations?

    If yes, please indicate your faith or belief (optional)

    Have you ever had any thoughts of harming yourself?

    Have you ever attempted to harm yourself?

    Have you ever harmed yourself to the extent where your life was at risk?


    Reasons for coming to counselling

    Please indicate the reason(s) that brings you to counselling (you may choose more than one):
    Emotional issuesDepressionAnxietyRelationshipsTraumaGriefEating DisorderAddictionBehavioural issuesSelf-growthLife and family planningCoachingCareerSchoolCultural issuesOthers

    Please briefly describe the reasons that bring you to counselling and what you would like to accomplish during the process:

    Which languages would you prefer to conduct your sessions in?

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