Intake Information Private & Confidential Personal Information Client Full Name Date of Birth: Address Telephone Number Email Address Emergency Contact Details Emergency contact name Emergency contact number Relationship Contact Preferences If I need to contact you in between sessions please advise how you would like me to contact you. Please select which contact options you prefer. PhoneTextEmail Please advise if there is a time of the day you wish not to be contacted. In the event of us meeting outside of our sessions such as in the supermarket, town centre etc please advise what you would like me to do. I am happy to pretend we don't know one another, to smile or say hello. Please bare in mind any questions you may be asked by others you are with if we do acknowledge we know one another. Brief History Have you had any previous counselling or therapy? Yes*No Do you have any major health problems for which you are receiving treatment? Yes*No Are you taking any medication at present? Yes*No *If you have answered "Yes" to any of the above, please provide further details as shown below. Statement My signature below indicates that: I have read and understand all of the information detailed in the Client Information and Data Protection Statement supplied to me. I agree to abide by the terms and conditions outlined therein. My signature below also gives permission for my Therapist to: Make contact with appropriate external agencies if they believe that I may be a danger to myself or to others. Client signature Please draw your signature below inside the dotted box. Details of previous counselling / therapy Details of current health problems for which I am currently receiving treatment Details of current medication Additional information that I might need to know Problems & Goals Introduction The purpose of this form is to have you write down what you see your current problems to be and also think about what you would like to achieve from therapy. Current problems? What do you see your current problems to be? Please be as descriptive as possible. What are the situations that keep these problems going or make them worse? What other comments, thoughts or feelings can describe how you view your problems? Therapy Goals: What do I want to achieve from therapy? Thinking about what you want to achieve from your therapy, tell me how differently you would see your life without your current problems and challenges:
