Application. Name * First Name Last Name Email * Phone (###) ### #### Address * Where you're currently based. Reasons * Reasons for seeking therapy Therapy * Past experiences in therapy/current or past diagnosis. Medical * Current general health and psychiatric status. Family * Relevant family history including past and present trauma. Spiritual * Describe your spiritual interest if any. Other Include any other relevant information you may want me to know. Session type * Session type Regular sessions One-off session Thank you!