New Client Intake Form

Hello and Welcome! I am so excited to be working together. In order to provide you with the best possible support, please fill out the client intake form below.

The fields below are purely to gain information that will likely be important in addressing any concerns or problems you might be facing. However, if you are uncomfortable answering any of the non-required fields we can always work our way up to them during sessions.

If at any point I believe I am not best suited or equipped to provide you with the support needed to address your concerns, I will be transparent and endeavour to find you a better suited practitioner. If this occurs during a session you will not be charged for that session.

While I work with sexual health, I am not a medical specialist. In some instances I may advice you to engage with a medical specialist or to engage with a GP for a health screening in order to rule out any serious underlying health issues.

Everything we discuss will remain strictly confidential, unless I believe you are of serious risk to yourself or someone else, or in the unlikely event your session notes are subpoenaed by court.

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Thank you for your response. ✨

Full Legal Name (First Name Surname )

Preferred name & pronouns

Date of Birth

Phone

Preferred Appointment Method

Gender
(gender referrers to your identity eg. Man, Woman, Non-Binary, etc.)

Sex
(sex referrers to your biological anatomy internally and externally)

Are you currently taking any medications? If yes, please specify

Do you have any medical conditions or have you previously had any serious medical conditions?

Do you have any psychological or other conditions?

Relationship Status

What is your primary reason/s for seeing me? This may include any problems, difficulties or goals.

What are you hoping to gain from our sessions? What would success, as a result of our sessions, look like?

Is there any additional information you would like to provide that you think may be beneficial for our work together?