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*Full Name:

*Date of Birth: *Age:

* Address:

*Phone Number: *Email:

*Emergency Contact Name:

*Emergency Contact Number:

*Relationship:

1. Are you currently under the care of a healthcare professional?

* Yes No

If Yes, please specify:

Name: Type of Professional:

2. Have you been diagnosed with a serious mental illness?

* Yes No

If Yes, please provide details:

3. Are you on any medications?

* Yes No

If Yes, list medication names:

4. Do you smoke?

* Yes No

5. Do you drink alcohol?

* Yes No

If Yes, how many drinks per day?

*Have you ever suffered from any of the following? (Tick all that apply):

Depression Anxiety Chronic Insomnia

Addictions Compulsive Disorders Drug Abuse

Eating Disorders Bipolar Disorder None of the above

Other (Please specify):

*Do you experience any of the following? (Tick all that apply):

Performance Anxiety Social Anxiety General Anxiety

Work Stress Relationship Stress Depression

Trauma/PTSD Stop Drinking Stop Smoking

Pain/Post-Operative Healing Behavioral Modification

Other (Please specify):

1. Do you have any concerns about your safety?

* Yes No

If Yes, please provide details:

2. Do you have any special needs or accessibility requirements?

* Yes No

If Yes, please provide details:

1. Are you a member of a health fund?

* Yes No

* I have read and understood the confidentiality and privacy policy.

* I understand and agree to the cancellation policy.

* I understand mandatory reporting obligations and agree to seek further information if needed.

*Sign Date:

*Signature:

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