Intake — Zack Young

Intake Form (v4.5nm)

Please complete this intake form for and on behalf of the client.

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Email

(###)

###

####

Any relevant medical history to share, including any active medications taken daily or weekly?

How would you describe your current mental health?

Looking ahead, what are you afraid of, or what brings you fear in your life and/ or the world?

What are your preferences and needs in communicating?

For example do you prefer audio only or also video calls, do you prefer shorter calls and do you need any assistance with summarising calls?

What is your primary goal for working together?

What secondary goals do you have for working together?

Is there anything else you'd like to share?