Adult Intake Form Personal DetailsName(Required) First Last PronounsDate of Birth(Required) MM slash DD slash YYYY Phone Number(Required)Email(Required) Address(Required) Street Address Address Line 2 City County Post Code Occupation (Optional)Emergency & Medical InformationEmergency Contact Name(Required) First Last Emergency Contact Phone(Required)GP Name & PracticeAbout YouThe following questions are optional. Please share only what feels comfortable. We can discuss these further during our sessions if you prefer.What has brought you to counselling at this time?What would you like to be different or to work towards through counselling?Are there any current or previous mental health difficulties, diagnoses, or experiences (including thoughts of suicide or self-harm) that you feel it would be helpful for me to know about?Are there any physical health conditions or medications that may affect your wellbeing or our work together?Have you had counselling or psychotherapy before?Have you had Do you have any concerns about addiction (including substances, alcohol, gambling, or other behaviours)?Do you have any accessibility needs or require any reasonable adjustments to help you access counselling?Is there anything else you would like me to know before our first session? This might include significant life experiences or anything you feel would be helpful for me to be aware of at this stage.Consent & Communication PreferencesPreferred contact method:(Required) Text Email Phone How did you find me? Google Directory Psychology Today Word of Mouth OtherConsent(Required) I Confirm I confirm that I have received and read the Privacy Policy and Therapeutic Agreement provided separately. By ticking this box and submitting this form, I acknowledge that I understand how my personal information will be collected, stored, and processed in accordance with the UK GDPR and the Data Protection Act 2018 for the purpose of providing counselling services, meeting legal and professional obligations, and safeguarding where required.
