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Intake Form

Completing and signing our consent forms before counseling ensures a transparent, professional, and respectful process. These forms outline counseling’s goals, confidentiality limits, and legal framework, protecting both you and our counselors. Your consent reflects our commitment to your well-being and a trustworthy therapeutic journey.

Intake Form

Name *

Surname *

ID No *

Gender *

Company *

Employee Number *

Cell Number *

Alt Cell Number

Home Address *

What problem are you seeking help with? *

Do you have any history of medical illness *

Yes

No

IF yes, please stateIF yes, please state

Do you currently on any medication? *

Yes

No

IF Yes, please stateIF Yes, please state

Name of emergency contact *

Number of emergency contact *

Relationship with emergency contact *

PLEASE TICK THE BOX(S) THAT APPLY TO YOU *

Headache

Dizziness

Have no appetite

Eating too much

Drinking alcohol to cope

Using drugs most of the time

Losing weight

Gaining weight

feeling sad

Body Ache

Crying spells

Excessive Guilt

Racing thoughs

Walking, talking or writing slower than usual

Forgetting easily

Getting irritated quickly

Cannot sleep

Sleeps too little

feeling tired most of the time

Thinking about committing suicide

Mood Swings

excessive energy

Anxiety attacks

Avoidance

If you are human, leave this field blank.

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