Client Intake Form – Roxana Cristina Alexandru

Counselling

Thank you for choosing to begin this work.

This form provides some background information that helps ensure our work begins with clarity, safety and shared understanding. You are welcome to answer the questions in a way that feels comfortable for you.

All information shared is treated with care and stored securely in accordance with UK data protection law.

About You

Full Name

Date of Birth

Email Address

Phone Number

Home Address

City / Country of Residence

Emergency Contact

Emergency Contact Name

Relationship to you

Phone Number

Emergency Contact

GP Name / Practice

GP Telephone Number

Your Reasons for Coming to Counselling

What brings you to counselling at this time?

What are you hoping counselling may offer you or support you with?

Have you previously experienced therapy or counselling?

Yes No

If yes, you are welcome to share a little about that experience.

Current Circumstances

Is there anything about your personal history or current life situation that you feel it would be helpful for me to know before we begin our work together?

What does your current living situation look like?

What is your current occupation or main daily activity?

Health and Support

Are you currently taking any prescribed medication?

Yes No

If yes, you are welcome to share a little about that experience.

Are you currently receiving any other form of therapeutic or mental health support?

No Yes, therapy or counselling Yes, psychiatric or medical support Prefer not to say

If you would like, you are welcome to share a little more.

Are there any physical health conditions or ongoing health concerns that you feel it would be helpful for me to be aware of?

Alcohol and Substance Use

Do you currently drink alcohol?

Yes No Occasionally

Do you currently use recreational drugs?

Yes No Prefer not to say

Practical Details

Preferred session format

Online counselling Walk and Talk therapy In-person sessions (when available)

Preferred days or times for sessions

Consent

I confirm that the information I have provided is accurate to the best of my knowledge. I understand that counselling sessions are typically 60 minutes in length and are usually held at the same time each week. I understand that confidentiality is an important part of the therapeutic relationship, with exceptions where there is a serious risk of harm to myself or others, or where disclosure is required by law.

I understand and agree

Privacy Notice

Personal information shared through this form is stored securely and processed in accordance with UK data protection law. Roxana Cristina Alexandru is registered as a data controller with the Information Commissioner’s Office.

I consent to my information being processed for the purpose of providing counselling services.

By submitting this form, you consent to your information being used to respond to your enquiry and provide services in accordance with the Privacy Policy.

Astrology Consultation Form

Reflective Astrology

Thank you for your interest in an astrology consultation.

This short form gathers the information needed to prepare your natal chart and offers an opportunity to share what you would like the session to explore.

My approach to astrology is reflective rather than predictive, using the chart as a tool for insight, self-understanding and meaningful reflection.