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* 1. Full Name

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* 2. Email Address

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* 3. Phone Number

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* 4. Date of Birth

Date

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* 5. What brings you to therapy? (Please select as many as you feel applies)

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* 6. Have you received therapy or counselling before? If so, please provide details.

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* 7. Are you taking any prescribed medication at the moment? If so, please provide medication name and dose.

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* 8. Is there anything else you would like me to know about you or your reason for seeking treatment regarding your mental health?

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* 9. Are you looking for face to face or online therapy?

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