Intake form

Name *

Email address *

What is your age?

What is your gender identity?

What is your primary reason for seeking counselling?

Please select at least one option.

Anxiety

Depression

Relationship Issues

Career Development

Stress Management

Self-esteem

Personal Growth

Have you previously attended therapy or counselling?

If yes, what type of therapy have you experienced?

Please select at least one option.

Cognitive Behavioral Therapy

Emotionally Focused Therapy

Gender Affirming Therapy

Sex Therapy

Are you currently taking any medications for mental health?

If yes, please specify the medications you are taking.

What are your goals for therapy?

How did you hear about bruno ferra holistic counselling?

Do you have any previous experience with holistic approaches to therapy?

Additional questions or comments

Bruno Ferra Holistic Counselling