Ember & Oak Therapy

Before your first appointment

Client Intake Questionnaire

This helps me get to know you before our first appointment, so we can spend more time on what matters most to you.

Before you start

Please answer as much as you feel comfortable with. If there are questions you would rather not answer, leave them blank — we can always talk them through together in session.

Only your name and a way to contact you are needed. Everything you share is treated confidentially, in line with the privacy information in your welcome pack.

It takes most people about 10 minutes. Set aside a quiet few minutes if you can — the form cannot be saved and returned to later.

Personal details

What you would like to be called.

Pronouns

Medicare and funding

Only needed if you plan to claim a rebate. Leave blank if it does not apply, or bring your card to your first appointment instead.

The number beside your name on the card.

Emergency contact

Does this person know they are your emergency contact?

Your wellbeing

How long have these concerns been affecting you?
What would you like support with?

Tick as many as apply.

What are some things that are important to you?

Health information

Including dose, if you know it.

Previous mental health support

Have you previously received counselling or therapy?
Have you ever had any significant mental health treatment?

For example, hospital admission, crisis team support or intensive outpatient treatment.

Have you previously worked with any of these?
Overall, how would you describe your sleep?

Therapy goals

The three most important things you would like to achieve

Preferences for therapy

What helps you feel comfortable in therapy?

Anything else

How did you hear about Ember & Oak Therapy?

Your answers are emailed straight to Amy Inglis and are not stored on this website. Email is convenient but never completely secure — if you would rather not send something in writing, leave it blank and raise it in session instead. How your information is handled is set out in the privacy policy.

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