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Therapy intake form
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CONFIDENTIAL This intake form is to be completed by all new clients. The answers you provide will become part of your confidential records. Should you have any queries, or require assistance with any of the below questions, please feel free ask me.
Ok, I understand
First name
*
Last name
*
Birthday
*
Day
Month
Month
Year
Address
*
Mobile Number
*
Email
GP Name and address
*
I hereby give my consent for you to collect and process the above information, as required by you, the therapist, for the pursuance of both my own and your legitimate interests. I have read, understood and I accept your Privacy Notice.
Yes
No
Have you had any previous treatment for psychological issues?
Yes
No
If yes, please give details – i.e. when, where, how long, provider name, medications etc
Are you currently taking (or in the recent past, taken) any prescription or over-the-counter medications?
Yes
No
If yes, please give details:
Does anyone in your family (blood relatives) suffer with any psychological problems?
Yes
No
Dont know
If yes please provide brief details
Do you use any recreational drugs?
Yes
No
If yes, please give details – what drugs, how often, last use etc.
Have you experienced hypnotherapy before?
Yes
No
If Yes please briefly let me know how long ago it was and describe what happened and how effective you felt this was?
Have you had any other types of therapy?
Yes
No
If Yes, please let me know below what you have experienced and how effective you felt it was?
Describe the issue you’d like to address?
*
Symptom checklist Sleep:
No problems
Not enough
Trouble getting up
Nightmares
Too much
Other
Appetite:
No Problem
No interest
Increased
Carbohydrate craving
Other
Energy:
Normal
Increased
Low
Up and down
Interest in Sex:
Normal
Increased
Low
Concentration:
Normal
Somewhat difficult
Poor
Terrible
Memory:
Good
Some difficulty remembering
Bad
Depressed or sad:
All the time
Most days
Some days
Not at all
Suicidal thoughts:
All the time
Most days
Some days
Not at all
Anxiety
All the time
Most days
Some days
Not at all
Anger/Irritation:
All the time
Most days
Some days
Not at all
Past suicide attempts:
Yes
No
Panic Attacks:
Frequently
Occasionally
Not at all
Any other comments you feel are important or relevant?
I give my permission for you to collect and process the above information, including any sensitive personal information as defined under the General Data Protection Act (GDPR), and as required by you, the therapist.
Yes
No
I have read, understood and I accept your Privacy Notice in respect of the handling of my recorded data
Yes
No
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