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Client Intake Form
Name
Date of Birth
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Preferred name
Email
Relationship status
Phone number
Occupation
Doctor's Name and Address
Address
Doctor's Post Code
Post Code
Medicatin being taken
Health Problems (Past & Current)
Why you seeeking therapy?
FROM THE LIST BELOW CIRCLE/TICK/HIGHLIGHT YOUR AREAS OF CONCERN
Addictions
Drinking
Smoking
Drugs
Gambling
Compulsive Behaviour
Anxiety/Depression
Trauma/Abuse
Stress
Fears/Phobias
Panic Attacks
PTSD/CPTSD
Childhood Problems/Trauma
Eating Problems
Food/Diet
Weight Problems
Anorexia
Bulimia
Exercise
Confidence
Self Esteem
Motivation
Achieving Goals
Procrastination
Public Speaking
Concentration
Exams
Memory
Sleep Problems/Insomnia
Tiredness
Pain
Mobility
Hearing
Sight/Vision
Skin Problems
Autoimmune Disorders
I confirm that I have been advised by The Practitioner of the scope of the therapies that she provides and give my full consent to receiving therapy sessions
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DISCLOSURE FORM
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Looking forward to work with you!
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