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*

 

 

Email*

 

 

Contact phone number*

 

 

Home phone

 

 

Work phone

 

 

City*

 

 

Address*

 

 

State*

 

 

Postcode*

 

 

Country*

 

 

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:

 

 

 

0 + 1 =