New Client Intake Form

Please fill out the following form.

First name

Last name

Preferred Pronouns

Date of birth

Day

Month

Year

Preferred Format (Online/In-Person/Flexible)

Preferred Time (Peak/Off-Peak/Flexible)

What would you like to achieve from your sessions?

What would success look like for you after working together?

What challenges are you currently facing?

How long have you been experiencing these challenges?

Rate the following on a scale of 1-10 (1 = very low, 10 = very high):

Short answer

Any relevant emotional, medical, or therapeutic history

Consent for Services

By signing below, I confirm that I have provided accurate information and agree to participate in sessions provided by Uplifting Mind.

Signature

Signature field is empty.

I declare that the info I’ve provided is accurate and complete.