Adult Counselling Intake form

If you have connected with me already and we’ve booked you in for a session, please fill out the intake form below before our first session.
Payment of $160/hour session, is due by etransfer to soulresiliencecounselling@gmail.com 24 hours within the session commencing.

Name

First Name

Last Name

Today's Date

YYYY

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Phone

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

How did you hear about me?

Are you currently having suicidal thoughts?

Yes

Describe what brings you to counselling and what you hope to gain through this process including any information you feel would be important for me to know

By typing my name below, I confirm that the information provided is accurate and true.

*Payment of $160/hour session, is due by etransfer to soulresiliencecounselling@gmail.com 24 hours within the session commencing. *