Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
How did you find me?
*
If you were referred by a past / current client of mine and you / they feel comfortable doing so, please include their name below. This is important to help me determine any potential conflicts of interest.
Are you looking for short- or long-term support?
*
Short term therapy is best if you are wishing to obtain assistance with a specific difficulty in a time-limited period (i.e., up to 6 months). Long-term therapy is best if you are wishing to obtain long-term support, obtain assistance with a number of difficulties that may have been experienced over a long period of time, and/or are wishing to explore your early life experiences, relationships, and/or traumatic experiences (generally 6 months +).
Please provide a brief description of what you’d like to explore together.
*
Please provide a brief description of any therapy you have engaged in so far. What did you do (if known), what was helpful (if anything) and what was unhelpful (if anything)?
*
What commitment are you willing/able to make to therapy?
*
Research supporting the effectiveness of psychological therapy is generally completed with clients who attend at least weekly sessions. Fortnightly sessions are an acceptable option if you are unable to commit to weekly sessions, or if you have already completed dedicated psychological work previously. I do not offer monthly or ad hoc sessions for new clients.
Please answer the following questions to help me discern whether my services are appropriate for your needs.
*
Have you ever been convicted of a violent crime?
*
Do you currently experience difficulties regulating anger, which has led displays of aggression (either verbally or physically)?
*
Are you currently, or have you recently (i.e., within the last 6 months) experienced suicidal thoughts that have felt unmanageable, including that has led to hospitalisation?
*
Do you experience difficulties in respecting others' boundaries in relationships?
Limits to my services
*
There are some important limits to my services. Please acknowledge all of the following:
