Intake Form

Please fill the form below before our first session. You can express yourself as much as you need.

What you write in this form remains strictly confidential. As a therapist this is my code of ethics (as regulated by the GHSC council).
By filling it, you help me to help you better and you help yourself to brainstorm on why you want to change.

1. Name (please include all names) *

First

Middle

Last

2. Best phone to reach you

To contact you in case I need. I won't use it for anything else.

3. Best email address to get in touch *

4. Occupation

5. What is your primary reason/goal for your sessions with me? *

6. Please list the benefits that you expect to gain from our sessions. *

For example, if your goal is to quit smoking, some benefits might be: "I want to feel healthier." or "I want to safe money.

7. Please list the 3 most important concerns regarding this issue, in order of importance. *

For example, if your goal is to quit smoking, some benefits might be: "I want to feel healthier." or "I want to safe money".

8. Have you made any previous attempt to address this issue? *

If "Yes", what did you do and what were the results?

9. Please list any other past/present significant physical/mental/emotional/spiritual challenges you feel important for me to know:

10. Do you have any relevant medical condition/s? *

If "Yes", please elaborate

Are you currently under a physician’s care for these conditions?

11. Are you currently under the care of a mental health professional? *

If yes, please specify

12. Are you taking any medication (not including vitamins and food supplements)? *

If yes, please list what they are and what they are for:

13. Do you take any drug? *

14. Have you ever being hypnotised before? *

If 'Yes", what for?

How was the experience?

15. Have you ever done other coaching or therapy before? *

If 'Yes", what for?

Did it help?

16. Do you meditate, or are you familiar with meditation? *

Yes, I meditate almost every day
Yes, I sometimes meditate
Yes, I have tried
No

17. Do you have difficulty with any of the following: *

Ability to sleep
Self-esteem
Relationships
Work
Energy level
Appetite
Other

18. What are sources of stress for you? *

19. Where did you hear about me? *

If there is anything else you'd like to share with me, please use this space her below.

Date *

Thank you for filling this out. I will review this and come back to you via email in 48 hours. Please could you type again your email address, to make sure it is correct? Thank you. *

Name

PAYMENT
The fee is payable by bank transfer, using the bank details here below:

Bank: HSBC
Account holder: Laura Artero
Account number: 81501909
Sort code: 40-07-06

Thank you.

Intake Form

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