🔐 Confidential Therapy Booking Form. All information shared is strictly confidential and protected.

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Full Name (or Preferred Name / Alias)

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Country of residence

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Contact details ^*

Please provide your contact information.

Age

Age in years

Gender ^*

Session Preferences ^*

Type of session you are booking

Preferred session format ^*

Reason for Seeking Therapy ^*

What brings you to therapy at this time? “You may share as little or as much as you feel comfortable.”

Trauma Context (Optional – Checkboxes Only) ^*

(No forced explanations) Which of the following best applies to you? (You may select more than one)

Current Emotional State (Self-assessment) (Helps therapist prepare, not diagnose) ^*

How would you describe how you’re feeling lately?

Urgency & Support Needs ^*

How soon would you like this session?

Consent & Trust Statement (Very Important) Checkbox required ⬜ ^*

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🔐 Confidential Therapy Booking Form. All information shared is strictly confidential and protected.

Full Name (or Preferred Name / Alias)

Country of residence

Contact details *

Age

Gender *

Session Preferences *

Preferred session format *

Reason for Seeking Therapy *

Trauma Context (Optional – Checkboxes Only) *

Current Emotional State (Self-assessment) (Helps therapist prepare, not diagnose) *

Urgency & Support Needs *

Consent & Trust Statement (Very Important) Checkbox required ⬜ *