New Client Form — Cenk Matalon, MA

Name

First Name

Last Name

Age

Phone

(###)

###

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Are you in a romantic relationship or married? For how long? Do you have any children? What would you like to explore with me about your romantic relationship(s)?

Are you in touch with your parents? How is your relationship with them?

Do you carry trauma? Please briefly explain. If yes, how is it impacting your life?

Do you have any active addictions (including porn)? Please briefly explain. How would your life be without this addiction?

Do you have a spiritual practice? If yes, please explain. How often do you practice? What seems to be missing in your spiritual practice or tradition?

Have you been in therapy or counselling before? What didn’t work for you about the work you’ve done previously? What more would you like to explore this time?

How did you hear about me?

Please add any additional information or comments.

Please fill the form below. This information is kept confidential.

If you’d like to do couples work, please fill out this form separately.