First Name:

Last Name:

Phone Number:

Email Address:

Marital Status:

Family Doctor:

What is the issue(s) you are seeking counselling to address?

How does the issue affect you on a day to day basis?

How long has this been an issue?

What else have you tried to remedy the situation?

Do you have any medical conditions that you take medication for?

If so, what is the condition and what medication(s) are you
currently taking?

Have you been to counselling before?

What do you hope to get from counselling?

Please list any other information that you think is relevant.