Client Intake Form

Thank you for choosing Eunoia Expressive Arts Therapy.

Please complete the following intake form before your first appointment. The information you provide helps support a safe, informed, and personalised therapeutic process.

All information is treated confidentially and managed in accordance with Eunoia Expressive Arts Therapy’s Privacy Policy.

Please enter your full legal name as it appears on your identification.
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What name would you like to be called during sessions?
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Please enter your date of birth.
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Please indicate whether you are seeking support for yourself or on behalf of a child.
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Please provide the best phone number to reach you.
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Residential Address
Please provide your full address including city and zip code.
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Country
Please provide the name of someone we can contact in case of an emergency.
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Please describe your relationship to this person (e.g. parent, partner, sibling, friend).
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Please provide the best phone number to contact your emergency contact.
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Referral Source
How did you hear about us?
Please describe what has prompted you to seek support at this time.
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What are your goals for therapy? What would you like to achieve?
Please list any existing supports you have (e.g., friends, family, services).
Is there anything else you would like to share with us?
I confirm that the information provided is accurate and I understand that submissions will be managed confidentially in accordance with Eunoia Expressive Arts Therapy’s Privacy Policy.
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