Client Intake Details

Title

Mr / Ms / Mrs / Dr / Mx etc.

Name *

First

Last

Date of Birth

e.g. 25/12/1980

Gender

Address

Please include your postcode

Contact Number

Name of Emergency Contact

e.g. Next of Kin / Partner / Friend

Emergency Contact's number

Name of GP

GP Address

GP Contact Number

Mental Health Team Contact Number

if applicable

Do you take any prescribed medication?

if applicable please provide the name and dose of the medication

Please provide a summary of what has brought you to therapy now

Please give details of any previous therapy you may have had

Please comment on anything else that you feel might be relevant to therapy

This 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?

Name