Initial Intake Questionnaire | Marble Psychological Services

Personal Information

Who is this intake form for? *

Myself (I am seeking therapy for myself)

My child or a child in my care

Someone else (partner, family member, friend)

Name of the person who will be receiving therapy *

Please provide the name of the person who will be attending sessions

Your Contact Information (person completing this form):

First Name *

Last Name *

Date of Birth *

Gender

Email Address *

Phone Number *

Please include country code (e.g., +95 for Myanmar)

Current Location (City/Country) *

Where are you currently based?

Your relationship to the person receiving therapy *

Session Preferences

Preferred Mode of Session *

Online (video call)

In-person (Yangon office)

No preference

Do you need a translator for sessions?

Yes

Which language do you need translation for?

Type of Support

What type of support are you seeking? *

Individual Therapy (Adult)

Child/Adolescent Therapy

Couple Therapy

Psychological Assessment

Other (please specify below)

Mental Health History

Have you received mental health support before?

Yes, with Marble Psychological Services

Yes, with another provider

If you've worked with a Marble therapist before, please share their name (optional)

If you prefer to see a different therapist, that's completely okay - just let us know in the additional notes section.

Please share any relevant details about your previous therapy experience

Are you currently taking any medication for mental health?

Yes

We'll discuss details during your session. This just helps us prepare.

How Did You Hear About Us?

How did you hear about Marble Psychological Services?

Additional Information

Is there anything else you'd like us to know?

Preferred therapist (if any)

Optional - we'll do our best to accommodate your preference based on availability and specialization.

Thank you for completing the intake form!

We've received your information and will get back to you within 24-48 hours to discuss next steps and schedule your first session.

If you have any questions or need assistance completing this form, please contact us.

Your information is confidential and will be stored securely in accordance with our Privacy Policy.

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