Resignify Clinic client intake form

This is the first step in starting your personalised therapy journey with us. By completing this secure form, you provide us with essential information that helps us understand your background, your concerns, and how we can best support you.

Your answers will remain confidential and enable us to prepare for your first session, ensuring that our approach is fully tailored to your needs. We appreciate you taking the time to share this information and look forward to supporting you on your path to mental well-being.

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Personal Information

All the information in this for are confidential.

Name:*

Email:*

Phone:*

Date of Birth:

Age:

Address:

Nationality:

Background Information

Level of Education:

other:

Profession:

Marital Status:

Emergency Contact (Next of kin)

Name:*

Relationship:*

Phone:*

Address:

Mental Health and Therapy Background

What led you to start psychotherapy?

Are you dealing with unpleasant emotions or behaviours right now? If yes, please describe:

Have you ever had Psychotherapy/Counseling before? If yes, when?

What are your expectations from Psychotherapy?

GP details:

Do you use any type of medication? If yes, please specify:

Do you suffer from any medical conditions? If yes, please specify:

Additional Information:

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