Adult Intake Form

Before we can schedule your first session, I would like to get to know more about you and what you are needing. Once you have submitted the form, I will get in contact with you as soon as possible to either schedule a free follow-up call or your first therapy session. If you are unable to fill out the form or have any questions, please reach out through the contact form. If required, visit the further support page for a list of urgent & additional services, some of which are available 24/7.

click here for details of specific Services, locations and pricing

Name of Client

First Name

Last Name

Date of Birth of Client

MM

DD

YYYY

Address of Client

Email Address of Client

Contact Number of Client

Next of Kin or Emergency Contact

Please provide the name and contact number of your next of kin or emergency contact (must be a responsible adult).

Q1: What are you needing support with?

Please list any challenges or difficulties that you would like counselling/ psychotherapy support to address.

Q2: What would you like to get out of counselling?

Please list any goals you might have.

Q3: Is there anything you would like me to know about you &/or your history?

Please include relevant diagnoses, prescribed medication, preferences/needs & anything else you feel is relevant to your care.

Q4: Are you currently experiencing thoughts of Suicide?

Do you currently experience or have you previously experienced (within the last 3 months) suicidal thoughts or behaviours? If you are currently experiencing thoughts of suicide, visit the "further support" page below for immediate support options.

Yes

No

Not comfortable answering

Q5: What kind of session/s are you interested in?

What session types are you interested in accessing? See session descriptions on "the work" page.

PERSON CENTERED COUNSELLING SESSIONS (12+)

PROCESS-ORIENTED PSYCHOTHERAPY SESSIONS (12+)

TARGETED SCHEMA AND EMDR THERAPY SESSIONS (16+)

CHILDREN’S THERAPY SESSIONS (6-12)

UNSURE

Consent & Confidentiality: By checking the box below, you agree that you are over the age of 18 and provide consent for Dorian to conduct an intake assessment based on any information provided via any correspondence. All information is confidential, however when subpoenaed by a court of law, or where risk of harm to yourself or someone else is identified, confidentiality may be broken in order to legally comply and/or to keep you &/or someone else safe.

I consent - as a client over the age of 18.