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The Irish Counsellor
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Intake form
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Name
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Email address
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What is your age group?
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Under 18
18-24
25-34
35-44
45-54
55-64
65 and above
What services are you interested in?
Please select at least one option.
Individual Counseling
Group Therapy
Family Counseling
Mental Health Assessment
Crisis Intervention
Substance Abuse Support
What is your preferred contact method?
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Phone
Email
In-person
Do you currently receive any mental health support?
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Yes
No
What are your primary concerns?
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Anxiety
Depression
Stress Management
Relationship Issues
Substance Abuse
Trauma
How did you hear about us?
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Friend/Family
Social Media
Online Search
Referral
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