Intake form

Help us serve you better

Name *

Email address *

What services are you interested in?

Please select at least one option.

Counselling

Alternative therapies

Clinical hypnotherapy

What is your preferred method of contact?

How did you hear about us?

Please describe your current mental wellbeing concerns.

Have you previously sought therapy or counselling?

If yes, please provide details about your previous experiences.

What are your goals for seeking support?

Do you have any specific preferences for your therapist?

Additional questions or comments

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Awakened life Mental wellbeing being