Pre-Session Form | THE CITY MONKSLIFE

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THE CITY MONK

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Pre-Session Form (Confidential)

First name*

Last name*

Birthday*

Day

Month

Year

Gender*

Male

Female

Others

Phone*

Email*

Address

Emergency Contact

Name *

Phone*

Main Concern

What brings you to Therapy?*

Goals for therapy

What would you like to achieve from the sessions?*

Current Situation

How long have you been experiencing this concern?*

Are you currently on medication or under treatment?*

Yes

No

If yes, please specify

Past history

Have you ever been to therapy or counselling before?*

Yes

No

Any past mental health diagnosis (if known)?

Lifestyle Snapshot

Sleep*

Good

Disturbed

Appetite *

Normal

Increased

Decreased

Substance Use( alcohol, Tobacco, etc.)*

Consent

I understand all therapies are confidential except in cases of risk of harm

I agree to participate in therapy sessions.

Terms and Conditions I read and I agree to the terms and conditions

Signature

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Date

Day

Month

Year

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First Name

Last Name

Email

Thanks for submitting!

THE CITY MONK

info.citymonk@gmail.com

7900063264

Mumbai

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