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Home
About Us
Our Services
Psychological Counseling Services
Dispute Mediation Services
Capacity Building Programs
Mental Health Advocacy
Peer Mediation
Events
Resources
Gallery
Contact Us
Book a Consultation
Psychological Counseling Client Intake Form
Full Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Email
Mobile Number
Emergency Contact (Name & Phone Number)
What are your main concerns? (Check all that apply)
Anxiety
Depression
Stress
Relationship Issues
Trauma
Self-Esteem Issues
Grief/Loss
Anger Management
Addiction
Workplace/School Stress
Suicidal Thoughts
Other (Please specify): ________
How long have you been experiencing these concerns? (Choose one)
Less than a month
1-6 months
More than 6 months
Over a year
On a scale of 1-10, how severe do you feel your concerns are? (1 = Mild, 10 = Extreme)
Have you had thoughts of self-harm or harming others? (Required)
Yes
No
If Yes, please explain:
Have you been diagnosed with a mental health condition before?
Yes
No
If Yes, please explain:
Are you currently taking any medication for mental health?
Yes
No
If Yes, please explain:
Have you ever been hospitalized for mental health concerns?
Yes
No
How do you usually cope with stress? (Check all that apply)
Exercise
Meditation/Prayer
Talking to someone
Writing/Journaling
Substance use
Sleeping
Avoiding others
Other
If Other, please specify:
Do you use alcohol or drugs?
Yes
No
How would you describe your sleep patterns? (Choose one)
Good
Inconsistent
Difficulty Falling Asleep
Frequent Nightmares
How would you describe your current relationships?
Supportive
Strained
Distant
Conflictual
Other
If Other, please specify:
Who do you turn to for emotional support? (Check all that apply)
Family
Friends
Partner
Therapist
No one
Other
If Other, please specify:
Are you currently in a relationship?
Yes
No
It’s complicated
What is your current occupation or student status?
Do work/school-related stressors contribute to your concerns?
Yes
No
What do you hope to achieve from counseling? (Check all that apply)
Emotional Support
Learning Coping Skills
Improving Relationships
Managing Stress
Self-Awareness
Healing from Trauma
Other
If Other, please specify:
What are your personal strengths that could support your healing journey?
• I understand that counseling is confidential, except in cases where I or others are in danger or as required by law. • I agree to participate in counseling services.
Agree
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