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Financial Trauma Therapist
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Intake Form
Please complete this form before your first appointment.
Contact
First Name
(required)
Last Name
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Email
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Mobile Phone Number
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Address
Country
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Australia
Address Line 1
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Address Line 2
Suburb
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State
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VIC
NSW
QLD
SA
WA
TAS
NT
ACT
Postcode
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Background
Date (dd/mm/yyyy)
(required)
Occupation
Are you currently in any form of relationship?
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Single
In a relationship
Married
Separated
Divorced
Widowed
Prefer not to say
Do you have any children?
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Yes
No
Prefer not to say
Health snapshot
How would you consider your general health?
1 — 5 scale
Have you previously seen a counsellor or psychologist?
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Yes
No
Are you on any medication from any previous issue?
Select
Yes
No
If yes, medication details
Are you currently experiencing overwhelming sadness, grief or depression?
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Yes
No
Have you ever had any suicidal thoughts?
Select
Yes
No
Has any family member identified with any mental health issue?
Select
Yes
No
Unsure
How would you consider your sleeping habits?
1 — 5 scale
How would you rate your current physical health?
1 — 5 scale
Do you do any form of exercise? If so, how often?
Select
None
1–2 times per week
3–4 times per week
5+ times per week
Goals
What is the main reason/s you are seeking therapy?
Is there any other information you think might be important?
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