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New Client Form

First name

Last name

Phone

Date of Birth

May a voice or text message be left on your phone? *

Yes

No

Address

Are you currently employed? *

No

Part-Time

Full-Time

Are you currently taking medication for depression, anxiety or any other psychological condition? *

Yes

No

Have you seen a counsellor or psychologist in the past? *

Yes

No

Was your experience ... *

Bad

Good

Don't Know

How did you hear about this counselling service?

What are your concerns for seeking counselling?

I have read and accepted the terms & conditions.

View terms and conditions

Thank you, I will be in contact with you shortly to book your session.

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EMBRACE YOUR FREAKDOM

because there is a little freak in all of us

Embrace Your Freakdom

because there is a little freak in all of us

readyto@embraceyourfreakdom.com

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©2023 by Embrace Your Freakdom.

I acknowledge all traditional custodians of all countries and pay respect to their elders past, present and future. May we never lose traditional wisdom.

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