Gestalt Therapy International

A community of dialogue

Programs around the world

Facilitating authentic living & working

Client Intake Form

New clients must fill out this form. If you are a couple, enter information for each person as a separate submission, and list your partner's name on your form for cross referencing.

If client is a child, fill in all the details, and put parents name as cross reference in the relevant box.

All information is strictly confidential. We do not, under any circumstances, give your information out to any 3rd party.

Client details

Fields marked in bold are needed.




First Name*



Last Name*






Contact phone number*



Home phone



Work phone


















Date of Birth*



Please indicate if you are currently on medication



Notes - please also include how you heard about us*


If a couple, name of partner; if a child, name of parent


Full Name


Contact in case of emergency


Emergency contact name*



Emergency contact phone*


Nominate therapy fee you will be paying


Nominated fee per hour*


Agreement and completion


Check to indicate agreement to having read and understood the disclosure statement*


Yes, I have read, understand and agree to the Informed Consent statement, including the cancellation policy

No, I do not agree


Insert todays date*




Please answer the following question:




2 + 0 =