Psychotherapy Consultation Form
Please complete this form before your first appointment. It provides the information required to begin our work together safely and effectively.
1 - Personal Details
Name
First Name
Last Name
Preferred Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
Region
Post Code
Address
Street Address
Street Address Line 2
City
Region
Post Code
Phone Number
Email
example@example.com
Pronouns (optional)
Gender Identity (optional)
Sexual Orientation (optional)
2 - Emergency Contact & GP Details
Emergency Contact Name
First Name
Last Name
Relationship
Phone Number
May I contact this person in an emergency?
Yes
No
GP Name
Practice
GP Phone Number
Consent to contact GP if serious safety concerns arise?
Yes
No
3 - Presenting Concerns
What has brought you to therapy at this time, and what would you hope to gain from it?
4 - Health & Previous Support
Please tell me about any relevant physical health conditions, current medication, and previous counselling, psychotherapy, psychiatric or mental health support.
5 - Risk & Safety
Current thoughts of suicide
Previous thoughts of suicide
Self-harm
Thoughts of harming others
Safeguarding concerns involving a child or vulnerable adult
If yes :
6 - Accessibility & Additional Needs
Do you have any accessibility, mobility, sensory, medical, or environmental needs?
Yes
No
If yes :
7 - Current Circumstances
Please tell me about your current circumstances, including relationships, work, study, family or support network.
8 - Alcohol & Substance Use
Please tell me about your current use of alcohol or any recreational or non-prescribed drugs that may be relevant to your therapy.
9 - Anything Else?
Is there anything important you would like me to know before we meet?
10 - Client Declaration
I confirm the information provided is accurate to the best of my knowledge.
Client Name
Date
dd/mm/yyyy
Signature
Submit
Submit
Should be Empty: