Client intake

Client Intake Questionnaire

Request for an Initial Support Session Thank you for reaching out. This questionnaire is designed to help me understand a little about you, what you are currently experiencing, and what you hope to gain from our conversation. Your responses will help me prepare for our meeting and make our time together as meaningful as possible. Please answer honestly and share only what you feel comfortable sharing.

Client Intake Questionnaire

Please fill out the questionnaire below to help me prepare for our initial support session.

Full name

Age

Phone number / WhatsApp number

Email address

Where are you currently based?

Briefly describe what has been happening in your life that made you seek this session.

How long have you been experiencing or dealing with this concern?

How has this situation been affecting your daily life?

Have you spoken to anyone or sought support concerning this issue before?

YesNo

If yes, briefly describe your experience (optional).

What have you tried so far to address the situation?

What would you most like to gain from our conversation?

If you could change or improve one thing about your present situation, what would it be?

Is there anything specific you would like me to understand about you before our conversation?

How would you prefer to have the session?

WhatsApp audio callPhone callVideo callOther (please specify)

Preferred date

What time is most convenient for you?

What is your time zone?

Are you currently receiving support from a qualified mental health professional?

YesNoPrefer not to say

Are you currently experiencing an immediate safety concern, such as thoughts of harming yourself or someone else, or being in danger from another person?

YesNoUnsure / Prefer to discuss this with a qualified professional

I confirm that I have read and understood the important information and consent terms, and agree to proceed.

I understand that this is an introductory, non-clinical support session (10 minutes) and not a substitute for professional mental health care.

Name (Acknowledgment)

Date (Acknowledgment)

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