Wylde Counsel— RSVP 1

Intake form

Thank you for choosing to begin your counselling journey with Wylde Counsel. To help us better understand your needs and provide the best possible care, please take a few moments to complete the following information.

Name

Name on ID (if different):

Pronouns

Birth date

YYYY

Phone

(###)

###

####

Home address and postcode

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your preferred means of contact

Living situation

With whom are you now living? Please list names, ages and relationship.

Physical health issues

Please list any physical health issues that you consider relevant to our working together:

Mental health conditions

Please list any diagnosed mental health conditions:

Do you consider these diagnosed health conditions to be accurate?

Do you have any accessibility requirements or preferences?

GP details

If you have a GP, please provide their name, the name of their medical clinic, and their contact details:

Emergency Contact

Please provide name(s), contact details and relationship to you:

Have you previously consulted with:

What was helpful or unhelpful during those consultations?

What prompted you to make this appointment?

Is your spirituality or faith something you would like to include or explore in counselling?

If yes, briefly explain:

What do I need to know about you to best support you?

If not you, please advise the name and contact details of the person or organisation responsible for payment:

Signed

Please enter your full name

Date signed

YYYY

Intake form

Location

Hours

Contact