EmailMe Form - Application for therapy or counselling

Name *

First Middle Last

Date of Birth *

Gender (optional)

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

Email *

Session Availability, eg preferred day's and times *

How did you find about Journey with John

Previous Counselling Experience. *

Have you ever engaged in counselling before? *

If Yes, what was helpful or challenging about your experience?

Presenting concerns, what brings you to counselling this time?, what do you wish to work on? *

Are you taking any medications ? *

Do you have any current or past physical or mental health conditions?

I accept the below consent *

I have read and understood the above. I consent to engage in services provided by Journey With John

Name *

First Last

Date Time *

DD / MM / YYYY