Complete the form below to book your appointment. All fields marked with * are required.

 

Session Preferences

Type of Therapist *
Preferred Language *Choose the language you are most comfortable speaking in.
Session Type*Select your preferred session format.
Virtual (Microsoft Teams)
Telephonic

Personal Information

First Name *
Surname *
Date of Birth *DD/MM/YYYY
Gender Assigned at Birth
Male
Female
Other
Prefer not to disclose
Country of Birth *
Do you have a South African ID?*
Yes
No
ID Number *Numeric only
0 (Min. 13 Characters)
Passport Number *

Contact Details & Address

Email Address *We will send your booking confirmation here.
Tel Number *
Alternative Tel
Street Address *
Suburb *
Province *
City *
Postal Code *
0 (Min. 4 Characters)

Emergency Contact

Contact Name *
Relationship
Contact Number *Enter emergency contacts phone number

Medical Aid (Optional)

Medical aid details are optional. INUA does not currently submit to medical aids.

Medical Aid Provider
Medical Aid Number
Main Member Name
Medical Aid Plan

Clinical Intake

This helps your therapist prepare for your session. All information is confidential.

What brings you to therapy today? *
Other Reason *
Please elaborate on what youre experiencing *
Have you attended therapy before?*
Yes
No
If yes, what type of therapy? *
Are you currently experiencing any thoughts of harming yourself or others?*Your safety is our priority. Please answer honestly.
Yes
No
If yes, please elaborate *
Are you on any medication?*This includes prescribed medication, over-the-counter medication, or supplements.
Yes
No
If on medication, please list *

If you are in immediate danger or experiencing a life-threatening emergency, please call your local emergency services or a crisis line immediately. Alternatively book for an appointment within 24 hours.

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About Your Health

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things*Select how often this has affected you in the past 2 weeks.
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
2. Feeling down, depressed, or hopeless*Select how often this has affected you in the past 2 weeks.
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
3. Trouble falling or staying asleep, or sleeping too much*Select how often this has affected you in the past 2 weeks.
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
4. Feeling tired or having little energy*Select how often this has affected you in the past 2 weeks.
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
5. Poor appetite or overeating*Select how often this has affected you in the past 2 weeks.
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
6. Feeling bad about yourself, or that you are a failure or have let yourself or your family down*Select how often this has affected you in the past 2 weeks.
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
7. Trouble concentrating on things, such as reading the newspaper or watching television*Select how often this has affected you in the past 2 weeks.
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
8. Moving or speaking so slowly that other people could have noticed, or the opposite - being so fidgety or restless that you have been moving around a lot more than usual*Select how often this has affected you in the past 2 weeks.
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
9. Thoughts that you would be better off dead or of hurting yourself in some way*Select how often this has affected you in the past 2 weeks.
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
PHQ-9 Total ScoreCalculated Field - Auto: Sum of Q1-Q9 (0-27).
0
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*This helps assess the impact of these problems on your daily life
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

Additional Information

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Please read our POPIA Policy, Privacy Policy and Terms & Conditions before consenting.

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