Client Intake Form

Please take the time to fill this form in and tell your story. The information you give helps us get the results you want. We will also use this form to reassess the progress you make and the outcomes you gain from working with us. This form is a great tool for helping you gain a clear perspective of what you are contending with. This form will remain strictly confidential.

Step 1 of 5

20%

Your name*
Date*
Date Format: MM slash DD slash YYYY
Mobile Number*
Suburb*
Email*
Date of birth*
Date Format: MM slash DD slash YYYY
Occupation*
Do you like it?*
Your family: Parents, siblings, children?
Describe your family dynamics:*
Are there any significant or unresolved family lineage problems or stories?*
Relationship history if relevant:
Prior Illness or Medical Conditions:
Are there any patterns of illness in your family?
Are you taking any medication, drugs or smoking?
What are the problems and issues you are currently experiencing?

What is the change and the difference you want to experience?You may want to list the things you want to resolve and the change/s you want to make, in order of preference.*
Do you have any problems or stresses in your life currently?*
Is there anything else you think we should know that may relate to the problems you've been having?*
Have you explored these issues in any other way or with any other therapists?*
How is your sleeping pattern currently?*

Do you have any favourite pastimes or interests?*
Are you comfortable in your own skin? Are you happy being you?*
Were there significant family beliefs or expectations that you grew up with?*
Sex*
- Female
- Male
As a female, is there any history of or any important experiences that come to mind, e.g. periods, childbirth, miscarriage, surgery or abortion, relationships, traumas etc?*
As a male, is there any history of or any important experiences that come to mind, e.g. medical events, traumas or relationships that you need to tell us about?*

Your story:*

Just a few more questions that can help us to provide a better service to all of our clients, thank you.
Where or how did you hear about us?*
Was it easy for you to book your session? Did you need further information or support in order to be able to book your first session?*
Do you have any fears or worries about working through your personal issues?*

Step 1 of 5

SIGN UP TO OUR NEWSLETTER

@INTUITIVE_INTELLIGENCE_SYDNEY