Willow Path Counseling
Therapy & Mental Wellness

Welcome — this is a safe space

Take your time. Share what feels comfortable; there are no wrong answers. This helps your counselor understand how best to support you.

About you
Priya Sharma
11 / 03 / 1994
[email protected]
(555) 670-3318
she / her
What brings you in
Persistent anxiety and trouble sleeping over the past few months, especially around work. I'd like tools to cope and feel more grounded.
Saw a therapist briefly in college. A close family member passed away last year.
How you've been feeling
Low mood Anxiety Sleep changes Low energy Difficulty focusing

Anything else you'd like to add: Some loss of appetite and feeling on-edge in the evenings

Emergency contact
Anil Sharma
Brother
(555) 882-4410
Confidentiality

I understand that what I share in counseling is confidential and will not be disclosed without my written consent, except where the law requires it — such as risk of harm to myself or others, or suspected abuse. I have had the opportunity to ask questions and I consent to begin counseling at Willow Path.

Priya Sharma
Client signature
June 17, 2026
Date

Willow Path Counseling · Everything you share here stays here.