Client Intake Form
Thank you for taking the time to complete this intake form. The information you provide helps ensure that therapy is safe, effective and tailored to your needs. All information is treated confidentially and stored securely in accordance with applicable data protection laws, including the UK General Data Protection Regulation (UK GDPR) and Data Protection Act 2018. Please answer as openly and honestly as you feel comfortable. Estimated completion time: 15–20 minutes
Personal Details
Full Name
*
First Name
Middle Name
Last Name
Telephone
Email
*
example@example.com
Home Address
Date of Birth
-
Month
-
Day
Year
Date
Age
Education
Occupation
Marital Status
Please Select
Single
Married
Civil Partnership
Separated
Divorced
Widowed
Children?
Yes
No
If yes, ages of children
Religious Beliefs
Sexual Orientation
Nationality
Primary Language Spoken
Immigration Status
Nature of Enquiry
Provide brief description of reasons for seeking therapy
Emergency Contact
Emergency Contact Name
*
First Name
Middle Name
Last Name
Relationship
*
Telephone
Email
example@example.com
Medical Information
GP Contact Details
History of Physical Illness?
Yes
No
If yes, please provide details of physical illness
History of Mental Illness?
Yes
No
If yes, please provide details of mental illness
Current Medication?
Yes
No
If yes, please list current medication
Any Addiction Issues?
Yes
No
If yes, please provide details of your addiction issues (drug, alcohol, gambling, sex, shopping, food, etc.)
Previous Support
Have you had previous counselling experience?
*
Yes
No
If yes, please provide details of previous counselling
Are you currently receiving therapy elsewhere?
*
Yes
No
Are other agencies involved in your support?
*
Yes
No
If yes, please provide details of other agencies involved
Risk & Safeguarding
Are there any Safeguarding Concerns?
Yes
No
If yes, please provide details of safeguarding concerns
Risk of Harm to Self or Others?
Yes
No
If yes, please provide details of risk
I give permission for the therapist to contact relevant agencies in an emergency
*
I agree
Personal History
Current Living Circumstances
Background Information, Family History
Significant Life Events / Trauma / Loss
Wellbeing Assessment. Rate below the areas of wellbeing
Sleep
*
1
2
3
4
5
6
7
8
9
10
Sleep Description
Food & Nutrition
*
1
2
3
4
5
6
7
8
9
10
Nutrition Description
Physical Health & Exercise
*
1
2
3
4
5
6
7
8
9
10
Physical Health Description
Mental Health
*
1
2
3
4
5
6
7
8
9
10
Mental Health Description
Family & Relationships
*
1
2
3
4
5
6
7
8
9
10
Family & Relationships Description
Sexuality
*
1
2
3
4
5
6
7
8
9
10
Sexuality Description
Leisure
*
1
2
3
4
5
6
7
8
9
10
Leisure Description
Work
*
1
2
3
4
5
6
7
8
9
10
Work Description
Menstrual Cycle (Women Only)
Desired Outcomes for Therapy:
Describe your hopes, aims and goals for your therapy
Availability for Sessions:
Terms & Conditions
GDPR Statement
*
I consent to the processing of my personal data in accordance with GDPR
Policies
*
I have read and understood the Privacy Notice, Cookie Policy and Data Retention Policy
Electronic Signature
*
Submission Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Submit
Should be Empty: