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Whitney Blacksmith
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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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18-24
25-34
35-44
45-54
55-64
65 or older
What is your ethnicity?
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Black
Mixed heritage
African
Caribbean
Other
What are your primary reasons for seeking therapy?
Please select at least one option.
Anxiety
Depression
Relationship Problems
Stress management
Self-esteem
Cultural identity
Trauma
Infertility
Other
Have you previously participated in therapy?
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Yes
No
How did you hear about us?
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Social media
Website
Friend or family referral
Community event
What days are you available for sessions?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What is your preferred method of communication?
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Video call
Phone call
Email
Do you have any specific preferences or requirements for your therapist?
Additional questions or comments
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