Welcome to APS. This helps us support you better.

This form is confidential and takes about 8-10 minutes. There are no wrong answers.

Personal details

1. Full name

2. Preferred name

3. Date of birth

DD/MM/YYYY

4. Gender

Male

Female

Prefer not to say

5. Phone number

6. Email address

7. Address

City, State

8. Emergency contact

Session type

Optional — helps us assign the right clinician.

Individual Therapy · 40 minutes

Couples Therapy · 80 minutes

Family Therapy · 80 minutes

Corporate / Wellbeing Session · Contact us

Psychological Assessment · 90 minutes

About your session

9. What brings you to therapy today?

10. How long have you been experiencing this?

11. Have you had therapy or counselling before?

Yes

12. What do you hope to achieve from therapy?

Wellbeing check-in

13. Current stress level: 5 / 10

14a. Sleep — hours per night

14b. Sleep quality

Good

Fair

Poor

15. Are you currently taking any medication?

Yes

16. Do you have any medical conditions we should know about?

Safety

17. In the past 2 weeks, have you had thoughts of harming yourself?

Yes

18. Do you feel safe at home?

Yes

Consent & policies

Consent to treatment: I understand the nature of psychological services at APS.Confidentiality: I understand my information is confidential except in cases of risk.Cancellation policy: 24-hour notice is required to reschedule without charge.Telehealth consent: I consent to online sessions via WhatsApp and understand the limits.

Signature — type full name

Date

Your information is protected under the NDPR and shared only with your assigned clinician, except in cases of risk of harm.

CARE | SUPPORT | RESTORE

Ibadan, Oyo State, Nigeria

Contact

aperformancesolution@gmail.com

+234 703 099 4867

Chat on WhatsApp

Pages

Book a Session
About APS
Intake Form
Assessments
Self-Referral
HR Referral

PHQ-9 and GAD-7 are copyright © Pfizer Inc. Used with permission for clinical purposes. WHO-5 © World Health Organisation. Workplace Stress Assessment © 2026 APS Psychological Consult and Services, adapted from established models for self-screening. All data is processed in line with the NDPR.