NEW CLIENT INTAKE FORM

PERSONAL INFORMATION:

First Name

Last Name

Age

Date of Birth

Ethnicity (Optional)

Religion (Optional)

Marital Status

Gender

Home Address

Telephone Number

EMPLOYMENT INFORMATION:

Are you currently working?

If you answered no to the above reason, please state why:

REASON FOR CHOOSING THE MIND CUSHION:

How did you find out about The Mind Cushion?

REASONS FOR SEEKING COUNSELLING:

What are your key concerns?

When did these problems begin, and what was happening in your life at the time?

PSYCHIATRIC AND MEDICAL HISTORY:

Have you been diagnosed with any psychiatric or mental health problems? If so, please state what you have been diagnosed with:

Have you been diagnosed with any physical health problems? If so, please state what physical health problems you are experiencing and have been diagnosed with

Are you on any medication? And if so, please state what medication you are on and why:

Please provide me with the name of your family doctor and their contact details:

Please provide me with the name of your psychiatrist (if you have one) and their contact details:

COUNSELLING GOALS:

What motivated you to come today?

What are your goals for counselling?

Is there anything else that you would like to mention?

I hereby authorise and consent to The Mind Cushion collecting and processing Personal Information in accordance and for purposes of the counselling service(s) in the contractual agreement with The Mind Cushion.

Thank you!

Micaela Kotzé

Wellness Counsellor

Owner of The Mind Cushion

ASCHP Membership Number: WC23/1696

NQF Registration Number: 895

NEW CLIENT INTAKE FORM

Contact

Business Hours

Monday - Friday

8.00am - 7pm

Saturday

8.00am - 12pm

Sunday + Public Holidays

Only available during emergencies

ASCHP Membership Number: WC23/1696 • NQF Registration Number: 895

© 2024 The Mind Cushion. All rights reserved.