Registration

01

About You

Full Name ✦

Date of Birth / Age ✦

Gender / Pronouns (optional)

Phone Number ✦

Email Address ✦

City / Country ✦

Education / Occupation

Preferred Language

Preferred Therapy Mode

Online In-person Hybrid

02

Emergency Contact

Name ✦

Relationship ✦

Phone Number ✦

03

Your Current Space

What brings you to therapy at this point in your life? ✦

04

Your Journey So Far

Have you been in therapy before?

Yes No

Have you ever received a mental health diagnosis?

Yes No Not sure

Have you experienced any of the following? (select all that apply)

This information helps your psychotherapist understand how to best support you.

Suicidal thoughts Self-harm Suicide attempt None of the above

Anything important you would like us to know from your past experiences? (optional)

05

Support & Medication

Are you currently taking psychiatric medication?

Yes No

Are you currently consulting a psychiatrist / prescriber?

Yes No

Anything you would like to share regarding medication or support? (optional)

06

Confidentiality & Privacy

Your space here is held with care.

Everything you share in therapy is confidential, except:

If there is risk of harm to yourself or others
If required by law

For supervision or professional development, your case may be discussed without identifying details. Your information will be stored securely and accessed only by the CIPR team for therapeutic purposes.

07

Important Understandings

Please check each statement to confirm your understanding.

Please check all four statements before continuing.

08

Sessions, Fees & Boundaries

Sessions

Typically 45 minutes
Regular attendance supports continuity

Cancellation Policy

Please inform at least 24 hours in advance
Late cancellations / missed sessions may be chargeable

Boundaries

Therapy sessions are the primary space for communication
Outside-session contact is limited to scheduling or essential communication unless discussed
Psychotherapists may not be available for immediate responses outside scheduled sessions

09

Final Reflection (Optional)

Before we begin — is there anything you feel is important for us to know about you at this moment?

10

Consent & Agreement

Please check all four statements to confirm your consent.

Full Name (as signature) ✦

Preferred Appointment Date ✦

At CIPR, therapy is not about fixing you, but about gently understanding and meeting yourself more fully.

Registration & Informed Consent

About You

Emergency Contact

Your Current Space

Your Journey So Far

Support & Medication

Confidentiality & Privacy

Important Understandings

Sessions, Fees & Boundaries

Final Reflection (Optional)

Consent & Agreement

Registration Received