Health & Background(This section helps assess how to support your wellbeing. Your responses are private and treated with care.) Do you have any health conditions or disabilities I should be aware of? (e.g., asthma, heart disease, diabetes, autoimmune conditions, epilepsy, allergies, etc.) Yes No Are you currently taking any medication or drugs? (This includes psychiatric meds, prescriptions, or recreational drugs.) Yes No Who do you currently live with? Alone Partner Family Friends Roommates Others How would you describe your relationship status? Single In a Relationship Married Separated/Divorced Others Do you have Children? Yes No What kind of work do you do? How would you describe your profession/employment? Have you been in counselling or therapy before? Yes No Do you currently have thoughts of harming yourself or ending your life? No Yes Have you had such thoughts in the past? No Yes Have you ever engaged in self-harming behaviours (e.g., cutting) or attempted suicide? No Yes Could you give a short description of the issues that are bringing you to psychotherapy now? (Feel free to write as much or as little as you like) Do you have any goals or hopes for what you’d like to gain from therapy? (Feel free to write as much or as little as you like) Thank you for your submission. We will reach out to you regarding scheduling via the email address provided in the form. If you experience any issues or do not receive communication from us, please contact us directly at info@sohamtherapy.com.