This intake form is to be completed and signed by all my new clients. The information you provide will become part of your confidential paper records, and will be destroyed within one year of your using my services. I keep no electronic records and do not share information. Once you have submitted this form I will contact you to schedule an appointment.
Your name
Your email
Your Skype or Zoom or Messenger address
Your date of birth
Your address and postcode
Contact phone number
Your occupation, if any
This part of the form allows you to tell me a little about the reasons you are asking for my help. Please include as much or as little information as you feel comfortable to share.
Describe the main problems
Can you think of a recent example when you felt like this? Describe what happened.
Is this situation typical of what happens? Where is it most likely to happen? When does it happen? Who are you most likely to be with? How does it happen?
How often does this happen? How distressing? How long does it go on for when it happens? How does it usually start?
What helps? What makes things better? E.g. avoidance, substances, safety behaviours
Impact - How does this problem affect your daily life? Work, home, family/friends, study
Coping resources - What helps you cope generally? Enjoyment, achievement, relationships, spirituality
What brings you to therapy at this time? How did you hear of me?
What do you hope to achieve in therapy? What will be different?
What medication do you take?
Do you use alcohol, drugs, tobacco, other substances? How much?
General mental state - Mood, concentration, memory, sleep, weight changes etc.
Risk – self-harm: thoughts, plans, likelihood to act etc. Other risks?
Previous therapy / treatment - What have you tried before? What helped? What didn’t help? Any other comments?
Is there anything else you'd like to tell me about?
Do you give consent for me, the therapist, to collect and process the information on this form for the pursuance of both my own and your own legitimate interests? (You must agree this to proceed)
You must put something in every box. So if the form does not send, check you have not left any empty.
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