Please fill the form below if this is your first time contacting us for therapy and a clinical psychologist will be in touch to book a session. If you are an existing client, simply send an email to therapy@initiative4equality stating your full name and requesting a session. Please enable JavaScript in your browser to complete this form.Name *Email *Whatsapp Phone Number *Skype ID (if you have)Are you currently receiving psychiatric services, professional counselling or psychotherapy elsewhere? *YesNoHave you had previous psychotherapy? *YesNoAre you currently taking prescribed psychiatric medication (antidepressants or others)? *YesNoWho was it prescribed by? *Please list the medication below *Do you currently have a primary physician or doctor? *YesNoAre you currently seeing more than one medical health specialist? *YesNoWhen was your last physical examination by a physician/doctor? (Select Date)Please list any persistent physical symptoms or health concerns you have (e.g. chronic pain, headaches, hypertension, diabetes, etc *Are you currently on medication to manage a physical health concern? *YesNoPlease list the health concern and medication below *Are you having any problems with your sleep habits? *YesNoCheck all that apply to youSleeping too littleSleeping too muchDisturbing dreamsPoor quality sleepHow many times per week do you exercise? *Zero1234567Approximately how long do you exercise for each time? *Are you having any difficulty with appetite or eating habits? *YesNoCheck all that apply to youEating lessEating moreBingeingRestrictingHave you experienced significant weight change in the last 2 months? *YesNoDo you regularly use alcohol? *YesNoIn a typical month, how often do you have 4 or more drinks in a 24 hour period? *How often do you engage recreational drug use? *DailyWeeklyMonthlyRarelyNeverDo you smoke cigarettes or use other tobacco products? *YesNoHave you had suicidal thoughts recently? *FrequentlySometimesRarelyNeverHave you had them in the past? *FrequentlySometimesRarelyNeverAre you currently in a romantic relationship? *YesNoHow long have you been in this relationship? *On a scale of 1-10 (10 being the highest quality), how would you rate your current relationship? *Zero12345678910In the last year, have you experienced any significant life changes or stressors? *YesNoPlease elaborate on the life changes or stressors *Have you ever experienced any of the following? Check all that apply or select 'none' *Extreme depressed moodDramatic mood swingsRapid speechExtreme anxietyPanic AttacksPhobiasSleep DisturbancesHallucinationsUnexplained losses of timeUnexplained memory lapsesAlcohol/Substance abuseFrequent body complaintsEating disorderBody image problemsRepetitive ThoughtsHomicidal thoughtsSuicidal thoughtsNoneRepetitive behaviours (e.g. frequent checking, hand washing)Are you currently employed? *YesNoState your current employer/positionAre you happy with your current position? *YesNoPlease list any work-related stressors, if anyDo you consider yourself to be religious? *YesNoWhat is your faith? *Do you consider yourself to be spiritual? *YesNoHas anyone in your family (either immediate family members or relatives) experienced difficulties with the following? Depression, Bipolar disorder, Anxiety disorder, Panic attacks, Schizophrenia, Alcohol/substance abuse, Eating disorders, Learning disabilities, Trauma history, Suicide attempts, Chronic illness. If yes, please list them below, with the family member. *What do you consider to be your strengths? *What do you like most about yourself? *What are effective coping strategies that you have learned? *What are your goals for therapy? *Submit
