Cāyu Intake Form

This form is here to help me understand a little more about you, and how best to support you. Everything shared is confidential.

Who You Are

First and Last Name

Birthday

Day

Month

Year

Age

How do you describe your gender? (You're welcome to write your own or leave this blank.)

What pronouns do you use (if any)? (e.g. she/her, they/them, he/him, or your own)

Mobile/Cell:

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Emergency Contact (name & relationship):

Emergency contact phone:

How did you hear about Cāyu?

Referred by (if applicable):

A Little Life Context

Relationship Status:

Children and their ages (if any)

Country of Birth:

Languages you speak:

Employment Status:

Occupation (if any):

Beliefs and Values:

Do you consider yourself to be spiritual or religious?

Yes

No

If yes, in what way?

What Brings You Here:

What’s led you to seek therapy at this time?

Are there particular themes or areas you’d like to explore?

What would you love to gain from our sessions?

Your Health & Wellbeing

Do you have any current medical or mental health diagnoses?

Are you currently taking any medication (physical or mental)?

Who is your GP? (name and contact if you're comfortable sharing)

Are you working with any other practitioners right now? (e.g. therapist, OT, naturopath, etc.)

Yes

No

If yes, please share their name, modality, and how often you see them

Do you give permission to contact your GP or therapist if needed?

Yes

No

Do you drink alcohol?

No, not at all

Occasionally — once or twice a month

Socially — a few times a week

Regularly — most days or daily

Do you use recreational drugs?

No, not at all

Occasionally — a few times a year

Sometimes — once or twice a month

Frequently — weekly or more

Do you experience sleep difficulties?

No, I sleep well most nights

Occasionally — I have trouble falling or staying asleep now and then

Often — I struggle with sleep on a regular basis

Ongoing — sleep has been a consistent issue for me for some time

Have you experienced any major stress or upheaval in the last five years?

Creativity & Past Support

Have you seen a therapist or counsellor before?

Yes

No

If yes, what kind and when?

Have you made art before in any form?

Yes

No

If yes, what kind?

Have you ever used art as a way to process or explore emotions?

Yes

No

If yes, feel free to describe

Session Preferences & Sensory Info

Do you have low blood pressure, are pregnant, or have any condition that may affect breathwork or movement-based practices?

Yes

No

Would you like soft background music during art-making or meditation?

Yes

No

Do you have any music preferences or sensitivities you'd like me to be aware of?

If you selected “I have sensitivities,” feel free to share any sounds or instruments you'd like to avoid.

Do you have any scent sensitivities (e.g. incense, candles, oils)?

Yes

No

If yes, please share

In-Person Session Preferences

Would you like organic tea during our session?

Yes

No

If yes, what kind of tea do you prefer?

Preferred milk (if any)

Before We Begin

Is there anything else you'd like me to know before we meet?

Thank you for taking the time to complete this form.

I appreciate the care you've taken to share this information. It helps me prepare thoughtfully for our work together.