Intake Form

General anxiety / restlessness

Poor self-esteem

Difficulties with making decisions

Thoughts of suicide

Postponing / Procrastination

Health anxiety or fear of having a serious illness

Difficulties with adjustment after traumatic events (accidents, assaults)

Depression

History of abuse

Loss / grief

Family of origin issues

Borderline personality disorder

Body focused behaviours (e.g., skin picking)

Anxiety about social situations

Lack of assertiveness

Difficulties with aggressive behaviour

Intrusive thoughts or obsessions

Worry thoughts

Difficulties with relationships

Addictions

Panic attacks

Isolating yourself

Feeling angry or irritated

Self-harming behaviours that are not meant to end in death

Adjustment to physical illness

Obsessive compulsive disorder

Adjustment to changes in life circumstances (move, loss of job, divorce etc.)

What Difficulties Do You Hope To Address in Therapy?