Please enable JavaScript in your browser to complete this form.TitleMr / Ms / Mrs / Dr / Mx etc.Name *FirstLastDate of Birthe.g. 25/12/1980 GenderAddressPlease include your postcodeContact NumberName of Emergency Contacte.g. Next of Kin / Partner / FriendEmergency Contact's numberName of GPGP AddressGP Contact NumberMental Health Team Contact Numberif applicable Do you take any prescribed medication?if applicable please provide the name and dose of the medicationPlease provide a summary of what has brought you to therapy nowPlease give details of any previous therapy you may have hadPlease comment on anything else that you feel might be relevant to therapyThis might include longer term topics or historical difficulties which are different to the main reason you are seeking therapy currently. E.g. difficulties with food / drugs or alcohol / self harm / sex / relationship difficulties etc.Are you happy to receive email reminders about your therapy appointments?YesNoCommentSubmit