Initial Assessment

Two people in a welcoming therapeutic conversation.

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Hello! Welcome. Tell me about yourself.

All information you share and everything related to therapy is confidential.

Symbolic image of mind, speech and self-knowledge.

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Understanding

This form helps me understand the main reasons that brought you here for your process of self-knowledge and personal development.

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They say our name is the word we like most. What is yours?

Name

A soft scene evoking childhood and place of origin.

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When were you born? Where do you live?

Date of birth

City and country

A vintage telephone in a welcoming therapy room.

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Your phone number? A friend to contact in an emergency? What is your email?

Phone / WhatsApp

Emergency contact

A person relaxing in a welcoming office.

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What do you do for a living? Married or single?

Profession

Marital status

MarriedSingleIn a relationshipPrefer not to say

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Have you had another therapy? For how long?

Previous therapy

YesNo

For how long?

Medication in a hand, without visible labels.

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Do you take medication? Which ones?

Medication

YesNo

Which ones?

Two chairs suggesting psychological care.

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Have you had, or do you currently have, psychological and/or psychiatric care?

Care

YesNo

A small figure walking through a wide landscape.

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Is there a family history of psychiatric illness?

Family history

YesNoI don't know

A sunflower in natural light symbolising emotional change.

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What would you like to change emotionally in your life? What miracle would you like to happen?

Emotional change

More confidenceMore lightnessOther

What miracle?

A person near a waterfall in a natural landscape.

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What is the main issue you want to work on?

Main issue

Anxiety/panicTrauma or difficult pastOther

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What impact does this issue have on your life and relationships?

Impact

Daily routineBody/healthOther

A person with open arms in a wide landscape.

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Allergies? Which ones? Any discomfort or pain in any organ or part of your body? Where?

Allergies

YesNo

Pain or discomfort

YesNo

Which one?

Hands in a gesture of prayer or reflection.

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Do you have a religion?

Religion

YesNo

A person sitting in a wide, quiet landscape.

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Any period where memories from a part of your life are missing?

Memory gaps

YesNoPrefer not to say

Natural food on a table, suggesting body health.

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Did anything change in your health after a significant event, such as intestinal or skin allergies, insomnia, migraines, rhinitis, esophagitis or recurring cystitis?

Health change after event

YesNoI don't know

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If yes, please explain

Explain, if you wish

A small leaf in the foreground before a path.

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In one sentence, summarize the issue you want to work on in this therapy.

One-sentence summary

An abstract health image without an alarming tone.

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Any chronic illness?

Chronic illness

YesNoPrefer not to say

Which one?

A calm road after rain, suggesting care and safety.

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Has any serious accident happened in your family?

Serious accident in the family

YesNoI don't know

A quiet landscape with a discreet symbol of remembrance.

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Any premature death in your family?

Premature death in the family

YesNoI don't know

Scales of justice without text or marks.

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Are there pending legal or inheritance matters in your family?

Legal or inheritance matters

YesNoI don't know

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Do you exercise regularly?

Regular exercise

YesNoSometimes

A fishing rod at sunset, symbolising a hobby.

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Do you meditate? Do you have any hobbies?

Meditation

YesNoSometimes

Hobby

A welcoming river and mountain landscape.

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Congratulations on taking this step.

Therapy is, above all, a journey of self-knowledge, learning and growth — and I am here to help you on it. — Fabio Morus

The information you share in this form is confidential and used solely for your clinical assessment and care. Your data will not be disclosed to third parties, except where required by law or when there is a risk to life for you or another person.

I have read the confidentiality statement and consent to the processing of my data for clinical assessment purposes, under the Privacy Policy.

Hello! Welcome. Tell me about yourself.

Understanding

They say our name is the word we like most. What is yours?

When were you born? Where do you live?

Your phone number? A friend to contact in an emergency? What is your email?

What do you do for a living? Married or single?

Have you had another therapy? For how long?

Do you take medication? Which ones?

Have you had, or do you currently have, psychological and/or psychiatric care?

Is there a family history of psychiatric illness?

What would you like to change emotionally in your life? What miracle would you like to happen?

What is the main issue you want to work on?

What impact does this issue have on your life and relationships?

Allergies? Which ones? Any discomfort or pain in any organ or part of your body? Where?

Do you have a religion?

Any period where memories from a part of your life are missing?

Did anything change in your health after a significant event, such as intestinal or skin allergies, insomnia, migraines, rhinitis, esophagitis or recurring cystitis?

If yes, please explain

In one sentence, summarize the issue you want to work on in this therapy.

Any chronic illness?

Has any serious accident happened in your family?

Any premature death in your family?

Are there pending legal or inheritance matters in your family?

Do you exercise regularly?

Do you meditate? Do you have any hobbies?

Congratulations on taking this step.