Intake FormPlease fill in this 5 minute form before your intake session. If there are any concerns or question please email me at nafisa@therapywithfisa.com.au Name * First Name Last Name Email * Date of Birth * MM DD YYYY Preferred Counselling Mode Please select your preferred method of Counselling. Zoom Video Phone Message Whatsapp Have you seen a Therapist before? Yes No Please indicate whether the following may be something you are interested in discussing in session: Crisis Safety E.g. Safety, Abuse, Trauma, Financial, Drug & Alcohol, Addiction, Homelessness etc. Relationships Family, Partner, Self, Children, Friends, Carer, Grief, Social, Spiritual etc. Study Related Academic Anxiety, Placement, Employment, Other etc. Referral Source Local GP Friends Instagram LinkedIn Referred from client Other Website Consent * Do you consent for this session to take place (at a time with which both parties are agreed upon)? Yes No Signature of Client * Please type your name Thank you for completing the Intake Form!If you have anything else you would like to add or change, please email nafisa@therapywithfisa.com.auI will be in contact within 48 hours.
