New Client Referral Form
Please complete the following questions as accurate as possible since they will assist us to assess your needs pre-appointment. In particular if you are being funded by Health Insurance, your name, address and other personal details need to match the insurance policy, or your request may be delayed. All information is held in the strictest confidence and compliant with the General Data Protection Regulations 2018 and Data Protection Act.
Client Information
Full name
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Full name
Address
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Street and number
Street Address Line 2
City
State / Province
Postcode
Date of birth
*
Date of birth - DD-MM-YYYY
Phone number
*
Phone number
Email
*
NHS number
*
Gender
*
Please Select
Male
Female
Non-binary
Gender fluid
GP / Doctor Surgery
*
Please provide the name of your GP or Surgery.
Career status
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Please state if you are a student, employed, self-employed, unemployed, or retired. If you are employed please state your job role and who is your employer.
Emergency contact
Name of Emergency contact
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Name of Emergency contact
Relationship with client
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Relationship with the client, e.g. parent, partner, sibling, professional
Email of Emergency contact
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Email of Emergency contact
Phone number of Emergency contact
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Phone number of Emergency contact
Therapies and Interventions
Have you previously received any type of mental health services?
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Yes
No
Are you receiving any therapy or support from mental health services at the moment?
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Yes
No
Please list any therapies or interventions received so far, and where you received them.
For example, CBT, Psychotherapy, Counselling, EMDR, inpatient psychiatric care
Have you ever had any criminal convictions, cautions, or been arrested?
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Yes
No
Do you have any open claims in court, for example, following a road traffic accident, workplace incident, discrimination, violent crime, displaced person status, modern slavery, human trafficking, and so on?
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Yes
No
Are you currently on psychiatric medication?
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Yes
No
Please list all psychiatric medications that you are currently taking (if applicable)
List all medication if applicable
Current symptoms
Please tick all the options that describe your current symptoms
I often experience;
fear of many things
shame
guilt
panic attacks
anxiety, excessive worry
low motivation
avoiding people or places
having nightmares
discomfort in social situations
sexual issues, including risky sexual behaviours
dissociation or depersonalisation (loss of time)
delusions or hallucinations
hopelessness
flashbacks
paranoia or suspiciousness
suicidal thoughts / attempts
memory problems
obsessive thoughts
violent thoughts
perfectionism
low self-esteem
easily distracted
Mood swings
unstable relationships
making many mistakes
Other
Main reason to request appointments
What is the main reason you are seeking this appointment at this time
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Psychological Therapy
Psychological assessment
ADHD assessment
Autism Assessment
Cognitive IQ assessment
Memory assessment
Mental Capacity Assessment
Learning Disability Assessment
Other
If you are looking for an assessment (e.g. ADHD, Autism, IQ) what is the main reason for this? is this for benefits application, academic or employment support, self-understanding, or medication treatment?
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Employment Support and Adjustments
Academic Support
Benefits application
Self-understanding
Seeking medication for my condition
Fitness to work
Immigration
Court Order
Other
What is your preference in attending appointments?
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Face-to-face at the clinic
Face-to-face outreach
Video ZOOM
Video TEAMS
Video Whereby
Other, please specify
Other, please specify here
Payment details
Who will be paying for your appointments?
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Myself or a Family member (payment is required prior to the appointment, we will contact you about this with further details)
Another organisation (for example, Health Insurance, Employer, Social Services, Accident Claim, etc, please provide details below)
For clients being funded by their employer, social services, GP, or any other organisation please provide the following details: Name of organisation, name of person authorising, their job role, telephone number, email address, postal address, and purchase order.
Please provide all details required, and ensure your name and address match the official records the organisation holds about you. Incorrect details will delay your treatment. Please be aware that you may be required to pay for the cost of your appointments, and you may need to claim the money back directly from whoever in funding these.
Clients funded by Private Health Insurance
For example, BUPA, AXA, WPA, CIGNA, etc. We need these details to be verified before any appointments can offered. Please check that your policy details are correct including your current name, home address, and so on, otherwise the Insurer will not cover the costs and you will have to cover the bill.
Health Insurance provider
Who is the Health Insurance with?
Health Insurance Policy number
What is your Health Insurance policy number?
Authorisation code
What is the authorisation or claim code given to you by your Health Insurance for this appointment?
Date of policy renewal
What is the date when your Health Insurance policy renews each year?
Excess liability
What is the excess you need to pay to us directly?
Policy limitations
What are the limitations on this policy, for example, certain amount each year, limits in costings?
Please be aware that the appointment will only be confirmed when all necessary documents and payment (if applicable) have been received.
Terms and conditions of service
At Dynamic Neuropsychology we take client consent and privacy very seriously. Please complete the form below to ensure you understand the terms of treatment, just tick YES or NO asappropriate. This form is necessary, for any work to start and continue. Thankyou so much.
1. During our appointments we collect basic client information and keep brief notes during therapy. This is necessary for therapy to continue. Do you consent to this?
*
Yes
No
2. We always send you reminders of appointments to your phone number, email address or home address if needed. We only contact you for these purposes. Please let us know if you change your phone number, email or home address. Do you consent to this?
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Yes
No
3. Confidentiality is guaranteed with some exceptions, for example if the Court or the Police ask for the records, or if we are concerned about your safety, or the safety of others, including public safety. In any case we will offer to discuss this with you beforehand. Do you understand the limits to confidentiality?
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Yes
No
4. Appointment fees will be agreed before any treatment starts. We may require advance payment before each appointment to secure the slot. Do you understand the fee terms?
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Yes
No
5. Appointment cancellations can be made up to 5 days before the appointment. Failing to attend the appointment or cancelling less than 5 days may incur a charge of the full fee. Please attend at the agreed time. Being later than 25% of the session time is deemed as a non-attendance. The only exception is during an emergency where evidence is required. If your sessions are funded by an organisation, like an employer or health insurance, you may still be liable to pay for the missed appointments, so please ensure you read the terms of your insurance policy. Do you understand the late cancellation or missed appointment terms?
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Yes
No
6. It is important that you come to therapy of your own free will and not be persuaded by anyone else. If you believe that you are being forced to attend therapy or to give us your consent, please let us know during your first appointment, and we will discuss the best support for you. Do you understand the importance of the above statement?
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Yes
No
7. If you wish, you may withdraw from therapy at any time by speaking with your psychologist and giving the required notice of 5 days. If you are unhappy about your sessions please speak with the psychologist first, who will attempt to make any adjustments. Do you understand your right to withdraw or request for adjustments?
*
Yes
No
If you are happy to submit this form please date and sign it below.
Please confirm that you are consenting to submit this form
*
Today's date
*
Today's date DD-MM-YYYY
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