Counseling Questionnaire - Cogent Coaching & Counselling

Legal First Name *

Legal Last Name *

The name you go by *

Email *

Phone *

Type of Meeting

Date of Birth *

Appointment Date *

The preferred date may vary upon the doctor’s availability.

Preffered Time

Morning (8am-12pm)
Afternoon(12pm-5pm)
Evening(5pm-8pm)

Have you been at out Medical before?

Yes
No

What is your primary reason for seeking counseling? (Select all that apply)

Other

How important is it for you to integrate your spiritual beliefs into the counseling process?

Very Important
Somewhat Important
Not Important

Would you prefer a counselor of the same gender?

Yes
No
No Preference

What are your preferred counseling methods? (Select all that apply)

What days and times work best for you? (Select all that apply)

Weekday mornings
Weekday afternoons
Weekday evenings
Weekends

Do you have any additional comments or specific needs you’d like us to be aware of?

Thank you for taking the time to complete this questionnaire. Your responses will help us better understand your needs and provide you with the most appropriate counseling services.