New Client Intake Form — Ponder and Pause Therapy

Section 01

Personal Information

Full Name *

Date of Birth (DD/MM/YYYY) *

Sex / Gender & Pronouns

Address *

Phone Number *

Email Address *

GP / Emergency Contact Name *

GP / Emergency Contact Phone *

Appointment Reminders

Text / SMS

Both

No reminders

Preferred Session Format

Online

In-Person

Section 02

Medical & Mental Health History

Are you currently taking any medication? *

Yes

Do you have any diagnosed medical or mental health conditions?

Yes

Prefer not to say

Have you previously received therapy or counselling?

Yes

You are not obligated to share anything at this stage that does not feel right. This information helps me to understand your situation more fully and to ensure the work together is as safe and appropriate as possible.

Section 03

What Brings You to Therapy

What brings you to therapy at this time?

There is no pressure to say everything here — share as little or as much as feels right at this stage.

How long have you been experiencing these issues?

Are there any recent life changes or events that may be relevant?

Section 04

Goals for Therapy

What would you like to achieve through therapy?

Goals can be broad and uncertain at this stage — it is entirely normal not to know exactly what you are looking for.

Are there specific areas you would like to focus on?

Section 05

Anything Else

Is there anything else you would like me to know before your first session?

This might include anything about your life, history or situation that feels relevant and that you would like me to be aware of from the start.

How did you hear about Ponder & Pause?

Form received.

Thank you for taking the time to complete this. Your responses have been sent securely to the practice. You will hear from me ahead of your first session.

Declaration & Submission

All information shared in this form is held strictly confidentially in accordance with professional standards, UK GDPR, and the Data Protection Act 2018. It will be used only to inform and support the therapeutic work. Further details are set out in the Privacy Notice and Therapeutic Agreement.

Submitted responses are sent securely to the practice. Fields marked * are required.