Client Intake Information

Email Address*

Your privacy is important to us. We will never share your email with anyone else

Name*

Please enter your first name followed by your family name

Address*

Please enter your full residential address including postcode

Occupation*

Date of Birth*

Your Current Age*

Mobile Number*

Landline Number*

Preferred Contact Method*

Emergency Contact Person*

Relationship Status*

Do You Have Private Health Insurance?*

If Yes, What Is The Name Of Your Insurer*

If not applicable enter None

Please List Any Known Allergies Or Intolerances*

If not applicable enter None

Do You Have Any Of The Following ?*

If You Have A Diagnosed Medical Or Mental Health Condition Please Describe*

If not applicable enter None

What Is The Name And Telephone Number Of Your Medical Doctor ?

Are You Currently Working With Any Other Therapist ?*

If not applicable, enter none. This information lets me know the kinds of self-care you have already engaged

Do You Have Any Children ?*

Please let me know their names and ages. If not applicable, enter None

Your Main Reason For Seeking Help From Shamarie ?

How Did You Find Shamarie ?*

thanks for your interesting in making an appointment with me. I will be my pleasure to help you achieve greater wellbeing and peace of mind.