Thank you for completing this form.

The information you provide will help me prepare for our first session. Please answer only what you feel comfortable sharing. We can discuss any of your answers in more detail during counselling if you prefer.

The information you provide will be treated confidentially and stored securely in accordance with UK GDPR and the Data Protection Act 2018. The limits of confidentiality, including safeguarding responsibilities, will be explained during our first session.

Young Person Intake Form

About You

Name(Required)
MM slash DD slash YYYY
Address(Required)

Parent/Carer Details (If Applicable)

Name
Does your parent or carer know you are seeking counselling?

Emergency Contact

Name(Required)

About You

Emotional Wellbeing
Have you experienced any of the following? (Please tick any that apply)

Health

Do you have any physical health conditions that you think it would be helpful for me to know about?
Are you currently taking any medication?
Have you been diagnosed with, or are you waiting to be assessed for, any neurodevelopmental condition (for example ADHD or autism)?

Previous Support

Have you had counselling or mental health support before?
Are you currently receiving support from any other service (for example CAMHS, a school counsellor, social worker or youth worker)?

Safety

Are you currently having thoughts of harming yourself?
Have you harmed yourself recently?
Are you worried you might harm someone else?
Is there anything happening at home, school, college or elsewhere that makes you feel unsafe?

Additional Information

I Agree
I confirm that I have read, understood, and agree to the terms and conditions outlined in the Therapeutic Agreement provided by Alice Gough Therapy. I understand the nature of the counselling service, including confidentiality, data protection, supervision, session commitments, cancellation policy, and my rights and responsibilities as a client.
By ticking this box and submitting this form, I acknowledge that this constitutes my electronic signature and confirms my agreement to be bound by the terms of the Therapeutic Agreement and to proceed with counselling on this basis.
I confirm that the information I have provided in this form is accurate and complete to the best of my knowledge.
I understand that the counsellor will explain confidentiality, including its limits, during our first session so that I know what information is kept private and the circumstances in which confidentiality may need to be broken.
I also understand that the personal information provided in this form will be collected, stored, and processed in accordance with the UK GDPR and the Data Protection Act 2018, and that it will only be used for the purpose of providing safe, ethical, and effective counselling services.
How did you hear about me?