Client Intake Form - Healing Is Here

Your answers to the following questions will be very helpful in assessing how best I can support you. Please complete as fully as you are comfortable, there is no obligation to answer every question.

Privacy Notice: All information you provide will be held confidentially by Marcus Sorensen in accordance with UK GDPR. Please see the Therapy Agreement for full data protection details.

Essential Information Required

* Required fields

Personal Details

Full Name *

Preferred Name

Pronouns

Date of Birth *

Address

Email *

Mobile Phone *

Emergency Contact

Name

Relationship

Phone Number

GP Details

GP Name / Surgery

GP Phone

What Brings You Here?

Please briefly describe what you hope to address in therapy *

Consent and Permissions

I confirm that:

Signature (type your name) *

Date *

Your Background Optional but helpful

The following sections help me understand your context better. Complete as much or as little as feels comfortable.

About You

Occupation

Is it fulfilling?

Relationship Status

Living Situation

Children (names/ages if applicable)

Previous Support

Have you received counselling, therapy, or psychological support before? What type and when?

Are you currently receiving any other support (e.g. psychiatrist, support groups, coaching)?

Neurodivergence

Do you have any neurodivergent diagnoses (e.g. ADHD, autism, dyslexia)?

Are you exploring or suspecting any neurodivergent traits?

Any accommodations that help you (e.g. written summaries, movement breaks)?

Family Background

Number of siblings

Your position in family

Parents still living?

Raised by

Brief description of your relationships with parents/caregivers (past and present)

Life Events & Lifestyle Optional

Significant Life Events

Major formative experiences (births, marriages, losses, spiritual experiences, transitions)

Traumatic or life-threatening events and when they occurred

Major stresses in your life currently

Current Medications & Treatments

Medications currently taken

Supplements or natural remedies

Other complementary treatments (e.g. acupuncture, osteopathy)

Lifestyle

Daily intake (approximate):

Water

Caffeine

Alcohol

Tobacco / smoking / vaping

Exercise (type and frequency)

Sleep (quality and quantity)

Medical History Checklist Optional

This section is optional but can be helpful for some presentations. Select: C (current), P (past), CH (chronic)

Psychological / Emotional	C	P	CH
Depression
Anxiety
Eating disorder
Mood swings
Addictions
OCD
PTSD
Panic attacks

Digestive	C	P	CH
IBS
Acid reflux
Constipation
Food intolerances

Neurological	C	P	CH
Migraines
Headaches
Insomnia
Dizziness
Seizures
Memory issues

Immune / Chronic	C	P	CH
Chronic fatigue
Fibromyalgia
Autoimmune
Allergies

Cardiovascular	C	P	CH
High blood pressure
Low blood pressure
Heart condition
Angina

Hormonal / Endocrine	C	P	CH
Thyroid issues
Diabetes
Hormonal imbalances
PCOS

Additional Medical Information

Any surgeries or hospitalisations

Family / hereditary health conditions

Any other health information relevant to your therapy

Finally...

What are your hopes and expectations for our work together?

Is there anything else you would like me to know?

Contact Preferences

Please indicate how you agree to be contacted (select at least one):