Further Information

Name

First Name

Last Name

Gender

Date of Birth

MM

DD

YYYY

Email

Phone Number

(###)

###

####

Can we leave a voicemail?

Yes

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

GP Contact Information

The name and contact information of your GP practitioner or practice

Emergency Contact

Is there anyone you would like us to contact in the event of a crisis? Please provide their name and phone number.

Are you currently taking any psychiatric medication?

Presenting Issues

Please briefly describe the reason(s) that you are seeking counselling

Additional Information

Are there any clarifications you'd like to make or anything you think that we should know about you before beginning the counselling process?

Lyon Counselling & Psychotherapy