Pychotherapy Client Intake Form Please fill out this Client Intake form before your first session. Name * First Name Last Name Date of Birth * MM DD YYYY Occupation Email * Phone number (###) ### #### Emergency contact name * Emergency phone number * Country (###) ### #### Your GP's name and contact details What would you like support with at this time? What would you like to experience or achieve through our work together? Do you have any current or past medical or mental health diagnoses, including any hospital admissions? Are you currently taking any medications? If so, please list them and their purpose. Who or what guided you to connect with Eugenie? What services are you interested in? Counselling Coaching Psychotherapy How did you hear about Eugenie's work? Option 1 Option 2 May Eugenie contact you by email with relevant updates, insights, or information about services? Yes No I have reviewed the Therapy Agreement, information about the therapy of my choice and understand how the treatment is carried out and what it involves * Yes No Need clarification Other Comments I understand that cancellations with less than 24 hours’ notice may not be eligible for a refund. I agree Date * MM DD YYYY Thank you for submitting your client questionnaire.I’ve received your form, and I appreciate you taking the time to provide this important information. It will help me prepare for your session and ensure our work together is as supportive and personalised as possible.If I need to clarify anything before we meet, I’ll be in touch. I look forward to working with you.Warm regards,Eugenie Young
