Mahalo (thank you)
for booking a Paʻa Counselling Session

Please fill in this form prior to your first session...

Legal name

Chosen name/s (if different from above)

Pronouns

Address

Phone

Birthday

Day

Month

Year

Emergency contact

Have you had counselling (or any type of talk therapy) before?

Yes

Was your experience with talk therapy mostly positive/negative? Do you know what worked/did not work for you?

If you havenʻt already shared this, or if itʻs changed, please share anything that you would like to work on and/or get out of these Paʻa Counselling Sessions

Is there anything that would be helpful to share about your lived experience?

Do you have any diagnoses that would be helpful to share?

Have you experienced any recent trauma and/or big life changes that you would like to share before your session?

Is there anything else that you would like to share?

Please read our cancellation + privacy policies via the link below:

https://www.blisstitute.com/policies

I have read and I agree to the cancellation policy

I have read and I agree to the privacy policy

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Mahalo (thank you) for booking a Paʻa Counselling Session Please fill in this form prior to your first session...

Mahalo (thank you)
for booking a Paʻa Counselling Session

Please fill in this form prior to your first session...