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INTAKE
WANT TO KNOW YOUR ATTACHMENT STYLE ?
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Intake form
You’re almost there — just fill out this form so I can understand how best to support you. This is a safe and confidential space.
Name
*
Email address
*
What is your age?
What type of counselling are you seeking?
Please select at least one option.
Low Self-Esteem & Self-Confidence
Life Direction & Identity
Anxiety & Overthinking
Stress & Emotional Burnout
Depression & Emotional Numbness
Relationship & Attachment
Child & Teen Counselling
What is your preferred session time?
Please select at least one option.
Monday 10:00 AM – 4:00 PM
Tuesday 10:00 AM – 4:00 PM
Thursday 10:00 AM – 4:00 PM
Saturday 10:00 AM – 4:00 PM
Sunday 12:00 PM – 4:00 PM
Wednesday 10:00 AM - 4:00 PM
Friday 3:00 PM - 5:00 PM
Have you previously attended therapy?
Select
Yes
No
What are your main areas of concern?
Additional questions or comments
Submit
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