Dr Helen Damon Initial Enquiry Form for Psychological Therapy

1

If you think I may be a suitable therapeutic fit for you, please complete this initial enquiry form. It takes approximately 5-10 minutes and helps me assess whether I may be a good fit for you, without requiring more of your time or information than necessary.

What happens next?

After reviewing your responses:

If I believe I may be a suitable therapeutic fit for you, I’ll email you to arrange a free Zoom call to discuss your therapeutic needs, preferences, and goals, and to decide whether to book a tester therapy session.
If I’m uncertain about my suitability, I'll email you to request further information.
If I believe I’m not a suitable therapeutic fit for you, I’ll email you to let you know and signpost you to alternative sources of support.

I aim to review and respond to enquiries as promptly as possible during working hours (typically Monday morning to Friday at noon).

Confidentiality and data protection

The information you provide on this form is treated as confidential and handled in line with the UK Data Protection Act (2018), GDPR, and professional guidance from the BPS and HCPC.

What I collect and why

I collect your name, email address, and brief information about your mental and physical health. This allows me to respond to your enquiry and assess whether I may be a suitable therapist for you.

How your information is used

Your information is used only for purposes related to your enquiry or therapy, including responding to you, assessing suitability, and, if we proceed, providing psychological therapy and keeping required records. Your data is not used for marketing.

Confidentiality

Your information is kept confidential and will only be shared if I am legally or ethically required to do so; for example, if there is a serious risk of harm, safeguarding concerns, or a legal obligation.

Storage and retention

If therapy does not proceed, your information will be securely deleted.

If therapy does proceed, your information will be stored securely in a password-protected client file and kept for seven years after therapy ends, in line with legal and professional requirements.

Statement of consent

By clicking "Next", I confirm that I have read and understood the information above. I understand the purpose of this form, how my information will be used and stored, and that submitting this form does not establish a therapeutic relationship. I consent to my data being processed as described.

2

Name* This field is required.

First Name

Last Name

3

Email* This field is required.

example@example.com

4

When are you available to attend weekly in-person sessions?* This field is required.Please select all days and times you could reliably commit to attending weekly, in-person sessions at Token House (EC2R 7AS). I do not offer less frequent or online sessions. Sessions for new clients are allocated on a first-come, first-served basis, subject to availability. If none of the options below work for you, this means I’m not a suitable therapeutic fit for you at present.

Mondays 8.30am-9.20am

Mondays 9.40am-10.30am

Mondays 11.10am-12pm

Tuesdays 1pm-1.50pm

None of the above days and times would work for me

Other

5

Are you aged 18 or above?* This field is required.

Yes

No

Other

6

Are you registered with a GP in the UK?* This field is required.

Yes

No

Other

7

Do you have an emergency contact based in the UK?* This field is required.

Yes

No

Other

8

Do you anticipate needing to cancel or reschedule sessions frequently?* This field is required.i.e., more than twelve per year, three in a row, or three per calendar quarter?

Yes

No

Other

9

Please briefly describe your anticipated pattern of attendance

10

Can you afford the session fee (£130) on an ongoing basis?* This field is required.Please note, I do not offer lower-cost sessions

Yes

No

Other

11

Can you pay for sessions by online bank transfer (BACS)?* This field is required.

Yes

No

Other

12

Will your sessions be funded by an insurance company?* This field is required.

Yes

No

Other

13

I have a 48-hour cancellation policy: if a session is cancelled with at least 48 hours’ notice, no fee is payable. If cancelled with less than 48 hours' notice, the session fee (£130) is payable in full. Do you consent to this policy?* This field is required.

Yes

No

Other

14

Are you currently experiencing acute psychological distress or crisis requiring urgent or emergency care?* This field is required.

Yes

No

Other

15

Do you have a criminal record or are you involved in criminal activity?* This field is required.

Yes

No

Other

16

Are you currently physically or psychologically abusing, neglecting, coercively controlling, or otherwise seriously harming someone else?* This field is required.

Yes

No

Other

17

As an adult, have you ever been physically violent towards others?* This field is required.

Yes

No

Other

18

Are you currently training as a mental health professional and required to have therapy as part of your training?* This field is required.

Yes

No

Other

19

To the best of your knowledge, do you have a close relationship with any of my current or former clients?* This field is required.i.e., do you anticipate speaking about any of my current or former clients as part of our therapeutic work?

Yes

No

Other

20

Are you willing to work in an exploratory way, without a predetermined session structure?* This field is required.

Yes

No

Other

21

Are you currently involved in, or do you anticipate being involved in, legal or regulatory proceedings where your mental health may be relevant* This field is required.

Yes

No

Other

22

Smoke-free practice policy:* This field is required.In line with the Health Act (2006), my practice operates as a smoke-free environment. To help reduce the transfer of third-hand smoke (tobacco smoke chemicals that can remain on surfaces and materials after smoking) into the therapy space, clients are kindly asked not to smoke tobacco for at least four hours before sessions. Please indicate your agreement:

I will comply with the smoke-free policy for all sessions

I am unable to comply with the smoke-free policy

Other

23

Are you currently receiving any mental health support?* This field is required.

No

Yes - individual therapy

Yes - couples therapy

Yes - group therapy

Yes – under the care of a psychiatrist

Other

24

Please briefly describe the topics you'd like to explore in therapy* This field is required.If you've already provided this information by email, you may add anything further here or type "N/A" and continue to the next question.

25

The questions below help me assess whether I could provide safe and appropriate therapy within the scope and capacity of my independent practice. I ask the same questions of all enquirers.

All responses are treated confidentially and will be securely destroyed if we don’t go on to book a tester session.

26

Do you have any formal medical or mental health diagnoses?* This field is required.

No

Yes

No formal diagnoses, but I suspect I may meet criteria for one or more diagnoses

Other

27

Please list all the medical and mental health diagnoses you have

28

Please list all the medical and mental health diagnoses you suspect you may meet the criteria for

29

Are you currently taking any prescribed psychiatric medication (e.g., antidepressants; anti-anxiety medication)?* This field is required.

No

Yes

Other

30

Please list all the names and doses of all the prescribed psychiatric medication you are taking

31

Have you ever experienced impulsive, obsessive, compulsive, or addictive thoughts or behaviours (e.g., substance misuse, OCD, or body-focused repetitive behaviour)?* This field is required.

No

Yes - currently

Yes - previously

Other

32

Please briefly describe your experience

33

Have you ever experienced an eating disorder, disordered eating, body dysmorphia, or other concerns about food, your body, or your appearance?* This field is required.

No

Yes - currently

Yes - previously

Other

34

Please briefly describe your experience

35

Have you ever experienced hallucinations, delusions, paranoia, or dissociation (e.g., losing track of time or surroundings, or feeling detached from your body)?* This field is required.

No

Yes - currently

Yes - previously

Other

36

Please briefly describe your experience

37

Have you ever been physically or psychologically abused, controlled, or coerced by someone else?* This field is required.

No

Yes - currently

Yes - previously

Other

38

Please briefly describe your experience

39

Have you ever experienced PTSD or panic attacks?* This field is required.

No

Yes - currently

Yes - previously

Other

40

Please briefly describe your experience

41

Have you ever self-harmed or seriously thought about physically harming yourself?* This field is required.

No

Yes - currently

Yes - previously

Other

42

Please briefly describe your experience

43

Have you ever attempted to kill yourself, made plans to do so, or had thoughts about killing yourself?* This field is required.

No

Yes - currently

Yes - previously

Other

44

Please briefly describe your experience

45

Please briefly note any other information you think I should know now to help me assess the safety and suitability of working together

46

Please note any questions you have about working together that you’d like me to respond to over email before we potentially book a Zoom call

47

Statement of Confirmation

By clicking "Review and Submit", I confirm that the information provided above is true to the best of my knowledge. I understand that, if we work together, I must inform you of any relevant changes.

48

Thank you for taking the time to complete this form.

Based on the your responses, it seems that I'm not a suitable therapeutic fit for you at this time. Your responses will be securely deleted, and I won't contact you.

If your circumstances change in the future, you're welcome to reach out again.

To help you find a suitable therapist, I recommend the following resources:

I wish you all the very best on your therapeutic journey and for your future.