Client Intake Form

Please complete the details below so Esther can prepare for your first session.

Preferred Session Date & Time

Select a date then choose an available time slot

Consent & No Harm Agreement (Click to expand)

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I agree not to harm myself in any way during or between counseling sessions. I understand that this commitment is crucial for my safety and well-being.

I acknowledge the following structures:

Open Communication: I will openly communicate any risk thoughts or feelings.
Crisis Plan: I will follow the agreed crisis plan if needed.
Emergency Contacts: I will provide accurate emergency contact details.
Counselor Support: I will engage actively in therapy.
Confidentiality: May be legally broken if direct safety is at risk.

Emergency Contact Information:

I confirm I have read and agree to this clinical structural statement.