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Client Intake Form – 1:1 Session with Johanne

Thank you for taking a few minutes to complete this form.

Your responses help me prepare our session and ensure that this work is appropriate and supportive for you at this time.

All information is confidential.

Basic Information

Full Name

EMAIL

Country and Time Zone

Have we worked together before?

Have we worked together before?
A
B

Section 2 - Your Intention

What brings you to this session right now?

How long has this situation or challenge been present in your life?

What have you already tried to address this issue (if anything)?

SECTION 3 — Desired Outcome

If this session were helpful, what would be different for you afterward?

Which approach are you most interested in?

Which approach are you most interested in?
A
B
C
D

SECTION 4 — Well-Being & Safety (IMPORTANT)

Are you currently under the care of a medical or mental health professional?

Are you currently under the care of a medical or mental health professional?
A
B
C

Have you ever been diagnosed with a serious mental health condition?

Have you ever been diagnosed with a serious mental health condition?
A
B
C

Please specify (optional)

Are you currently experiencing any of the following?

Are you currently experiencing any of the following?
A
B
C
D
E
F

SECTION 5 — Readiness

Are you willing to actively participate in the session process?

Are you willing to actively participate in the session process?
A
B

Is there anything important you would like me to know before our session?

SECTION 6 — Agreement (MANDATORY)

This session is intended for personal growth and support. It is not medical, psychological, or psychiatric treatment and does not replace professional healthcare.

By proceeding, you acknowledge that you are responsible for your own well-being and participation.

This session is intended for personal growth and support. It is not medical, psychological, or psychiatric treatment and does not replace professional healthcare. By proceeding, you acknowledge that you are responsible for your own well-being and participation.