CLIENT INTAKE FORM Client Information Client Name (First, Last) Preferred Name Full Address Phone Email Confirm email Date of Birth (MM/DD/YYYY) Age How did you hear about Muslimah Therapy? —Please choose an option—Referral from a Mental Health professionalReferral from a family member/friendFacebookInstagramOther Please specify: Are you currently seeing a Psychiatrist, Psychologist, Psychotherapist or other Mental Health professional? YesNo Have you been in therapy or counselling in the past? YesNo What are some of your goals for therapy now? What would you like to work on in your Expressive Arts Therapy sessions? Emergency Contact Information Full Name (First, Last) Relationship Phone Email Digital Signature: By checking this box and typing my name below, I am electronically signing this form. Client Name (First, Last) Date (MM/DD/YYYY)