Initial assessment form

Full name

Date of birth

Phone / WhatsApp

Include your country code.

Emergency contact (name and phone)

Address (city, country)

Profession

Marital status

Have you had other therapy?

Which therapy?

Do you take any medication?

Which medication?

Have you had psychological/psychiatric care?

Family history of psychiatric illness?

Any chronic illness?

Allergies?

Which allergy?

Any discomfort or pain?

Where or how do you feel it?

Any periods of memory loss?

Do you exercise regularly?

Are meditation or hobbies part of your routine?

Which practice or hobby?

What brought you here?

What brought you here?

What is the main issue you want to work on?

Which issue?

Where does this issue most affect your life?

How does it affect you?

What would you like to change emotionally?

What would you like to change?

If a miracle happened, what would change first?

What would change?

Which sentence best summarises what you want to work on?

Write your sentence.

Any serious accident in the family?

Any premature death in the family?

Any pending legal or inheritance matters?

Did anything change in your health after a significant event?

If yes, please explain.

Do you have a religion?

Which religion?

Consent

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 — to you or to another person — in which case confidentiality may be broken to protect life, in line with applicable ethical principles.