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Intake Form
Hi there. To help us help you, please fill out and submit this short form. We'll then get in touch to organise your first session.
9
Questions
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1
Name
First Name
Last Name
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2
What is the reason for your booking? You can choose more than one.
Alcohol use
Anxiety
Adjustment
Attention deficit
Bereavement / Grief
Bipolar
Child / Adolescent Psychology
Couples counselling / Relationship therapy
Co-occurring anxiety and depression
Depression
Drug use / Addiction
Eating
Gender or sexual identity-related issues
Obsessive compulsive
Panic
Phobia
Post-traumatic stress
Psychotic
Schizophrenia
Sexual
Sleep problems
Stress
Work-related Issues
Other
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3
Do you have a current Mental Health Care Plan? This would have been developed by your GP.
Yes
No
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4
Where would you like to see the therapist?
Face-to-face
Online
Either face-to-face or online
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5
What day(s) of the week are you available for sessions? You can choose more than one.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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6
What times(s) of the day are you available for sessions? You can choose more than one.
Morning (8am - 11am)
Middle of the day (11am - 2pm)
Afternoon (2pm - 5pm)
Evening (5pm - 7pm)
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7
Ok, we've got a sense of how we can support you. How would you like us to first contact you?
Email
Call
Either email or call
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8
Email
example@example.com
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9
Mobile Number
04XX XXX XXX
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