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Client Intake Questionnaire - The Lighthouse Counselling
Please fill in the information below and before your first session. Please note: information provided on this form is protected as confidential information.
You may also return the completed form by submitting here or email to
hello@tlhcounselling.com
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* Indicates required question
Full name (First name, Last name)
*
Your answer
Phone (please provide country code)
*
Your answer
Email
*
Your answer
Age
*
Your answer
Marital Status
*
In a relationship
Single
Married
Divorced
Other:
Gender
*
Male
Female
Emergency contact number (please state family, friends, etc.)
Your answer
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? If yes, when was that?:
Your answer
Are you currently / previously been taking any prescription medication? If yes, please list:
Your answer
How would you rate your current physical health?
Poor
1
2
3
4
5
Very Good
Clear selection
. How would you rate your current sleeping habits?
Poor
1
2
3
4
5
Very Good
Clear selection
Are you currently experiencing overwhelming sadness, grief or depression? If yes, please provide details:
Your answer
Are you currently experiencing anxiety, panics attacks or have any phobias? If yes, please provide details:
Your answer
Are you currently in a romantic relationship? If yes, please rate your relationship from 1 (poor) to 10 (very good)
Your answer
What significant life changes or stressful events have you experienced recently?
Your answer
In section below, identify if there is any history of any of the following. If yes, please provide details:
Alcohol/Substance abuse
Anxiety
Depression
Eating disorders
Obsessive compulsive behaviours
Suicidal
Addiction
Other:
Are you currently employed? If yes, please rate from 1 (poor) to 10 (very good):
Your answer
Do you consider yourself to be spiritual or religious? If yes, describe your faith or belief:
Your answer
What would you like to accomplish out of your time in the therapy?
Your answer
Please suggest your preferred time slots and indicate "face to face / online" for your first session:
*
Your answer
Please indicate your preferred choice of therapist
*
Belinda Lau - Principal Therapist
Monika Verma - Associate Therapist
Beverly Foo - Associate Therapist
Scarlette Yuen - Associate Therapist (only online sessions)
Susanna Wong - Associate Therapist (only online sessions)
Sarann Johnson - Associate Therapist (only online sessions)
Required
How did you find us (please indicate the source)? Otherwise, referred by (if any)
Your answer
Comments
Your answer
Important: please read below link before our sessions. By submitting this form you are agreeing to confidentiality terms at the link. Thank you.
https://docdro.id/rG6IvQl
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