CLIENT INTAKE FORM

Please share as much information as you can in this obligation-free client form below. This will aid my understanding of your current problem/s.

You may also request a Client Intake Form by email.  

072 178 9870

shariefaj67@gmail.com

Full Name *
Gender *
Home Address *
Date of Birth *
Cellphone number *
Email Address *
Next of kin contact number *
Occupation

Please indicate the type of support you require: 

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For how long have you been living with the current problem? *
Have you ever received counselling before?  *
How would you describe your general health? *
Please list any medications, supplements, and/or homeopathic remedies you have tried:  *
Have you been diagnosed with any physical medical condition in the past 6 months? *
How has your problem affected your usual daily routine? *

Preferred mode of counselling

 *

Ideal location for counselling

 *

By filling in this form, you allow Healing Holistically to contact you back. 

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AFFILIATIONS & QUALIFICATIONS

 

 

BA in Health and Social Services with specialisation in psychological counselling (with distinction in psychology) (UNISA)

BSoc Sci in Criminology (UCT)

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Applied Metaphysics (Metavarsity)

Reiki

Meditation and Mindfulness practice

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FURTHER TRAINING AND DEVELOPMENT

As a counsellor I keep up with any developments in the field by completing annual Continuous Professional Development (CPD) training