CLIENT INTAKE FORM InstagramThis field is for validation purposes and should be left unchanged.Welcome to Monad Centre of Balance. Thank you for taking a few minutes to complete this form before your therapy. Your responses help us understand how best to support your wellbeing. All information is confidential and managed in accordance with our Privacy & Communication Policy.Name(Required) First Last Email(Required) Phone(Required)Date of Birth(Required) DD slash MM slash YYYY Emergency Contact Name First Emergency Contact PhoneWhich Services are you Attending(Required) Holistic Counselling & Mind-Body Medicine Mental Health Planning & Life Coaching Flower Essence Clarity Therapy Spiritual Mentoring Integrated Energy Healing Select AllSession Date(Required) DD slash MM slash YYYY How are you feeling coming into this session?(Required) Calm and balanced Slightly stressed or unsettled Emotionally tired or overwhelmed Unsure or wanting clarity What would you like to focus on in this session?(Required)Background InformationHave you had any therapy or counselling before? Yes No Please share briefly what type of support you received.Do you have any ongoing medical conditions or take medication? Yes No Please share briefly what type of support you received.Your Wellbeing SnapshotWhat areas of wellbeing feel most important for you right now? Stress or emotional balance Anxiety or low mood Relationships or communication Grief or life transition Physical symptoms connected to stress Life purpose or spiritual connection Other (please specify) Please SpecifyWhat practices or supports currently help you? Meditation or mindfulness Physical activity Time in nature Creative expression Talking with others Other (please specify) Please SpecifyWhat do you hope to gain from therapy or ongoing sessions?Consent and ConfidentialityConsent I understand and consent to receive therapeutic services from Iva Parker-Puie — Holistic Counsellor, Mind-Body Medicine Therapist, and Mental Health Life CoachAll sessions are conducted with respect for your privacy and wellbeing. Information shared in therapy is confidential except where required by law or where there is risk of harm to self or others.Signature
