1. Part One
    (introduction)
  2. Part Two
    (Select Problems)
  3. Part Three
    (Any Medication?)
  4. Part Four
    (Subconscious Mind)
  5. Part Five
    (Contact Info)

Client Information (Confidential)

Before going ahead with Therapy over the internet or by telephone it is important that I have some information from you that will be relevant to your therapy. This form is designed to give me information that I can use to help you with your particular problems.

It is also designed to help you to begin thinking more indepth about your life and to view your life in a new way. Everything you write on this form is kept confidential and is transmitted over a secure server. Each question can be answered with as much or as little detail as you choose. All I ask is that you answer with the very first uncensored thought that springs to mind.

How did you hear about Reachout Psychotherapy?

What is the main problem you are experiencing?

When did it begin to bother you?

What do you wish to get from therapy?

Have you sought therapeutic help before?
Yes | No

Are you in employment and what do you do?

Are you happy with your current work situation? If not, please give reasons.

How do you spend your free time?

Do you have any hobbies or interests? If so what are they?


Clear my information and all forms and destroy this session.

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