New Client Intake

New Client Questionnaire

One Life Services · Confidential · Takes about 5–10 minutes

Your responses help us understand your needs before your first session and ensure we can provide the most relevant, personalized care. All information is kept strictly confidential. Take your time and answer as fully as you're comfortable.

About You

Let's start with some basic information so we can get to know you.

Full Name *

Preferred Name

Date

Age

Pronouns

Email *

Phone *

Step 1 of 4

Your Goals

Help us understand what brings you to therapy and what you hope to achieve. There are no right or wrong answers.

What brings you to therapy at this time? *

Primary goals for therapy

Current mental health concerns (optional)

Life areas you want support with

Previous therapy experience

Current medications (optional)

Step 2 of 4

Safety, Supports & Logistics

This section helps us ensure we can provide the safest, most appropriate care for you. Your answers are confidential.

⚠️ Crisis Resources: If you are in immediate danger, please call 911 or the Suicide & Crisis Lifeline at 988. This practice does not provide emergency or crisis services.

Have you had thoughts of self-harm in the past 30 days? *

No Yes Prefer not to say

Have you had thoughts of harming others? *

No Yes Prefer not to say

Personal strengths

Support system

Cultural, spiritual, or identity factors

Scheduling & Session Preferences

Preferred session frequency

Preferred session times

Comfortable with telehealth? *

Yes No I have questions

Selected session fee *

Anything else you'd like us to know?

Step 3 of 4

Review & Submit

Please review your answers below. When you're ready, click Submit to send your questionnaire to the One|Life team.

About You

Your Goals

Safety, Supports & Logistics

Confidentiality reminder: Your responses are confidential and will only be shared with your assigned therapist at One|Life Wellness. Submitting this form sends your information directly to our secure inbox.

Step 4 of 4