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Client Intake Form

Name

Date of Birth

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

I confirm that I read and accept all terms and conditions as stated in Disclosure Form

DISCLOSURE FORM

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Looking forward to work with you!

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