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 Have you ever attempted to take your own life? No Yes Have you had such thoughts in the past? No Yes Have you ever engaged in any kind of self-harm? Self-harming is the act of harming your own body on purpose, such as by cutting, burning, hitting yourself. It may also involves hair pulling, scratching, bruising. It's usually not meant as a suicide attempt. This type of self-injury is a way to cope with emotional pain, sadness, anger and stress. 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.