Mahalo (thank you)
for booking a Paʻa Counselling Session

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

Full legal name

Chosen name/s (if different from above)

Pronouns

Address

Phone

Birthday

Day

Month

Year

Emergency contact name + phone number

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

Yes

Was your experience of this mostly positive or negative? What worked well for you/didnʻt work for you?

If you haven't already shared this, or if it's changed, please share anything that you would like to work on/get out of you Pa'a Counselling Session/s

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

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

Is there anything else that you would like to share before your session?

Please read our cancellation + privacy policies here: https://www.blisstitute.com/policies

I agree to the Cancellation Policy for Paʻa Counselling Sessions

Yes

I agree to the Privacy Policy for Paʻa Counselling Sessions

Yes

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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...