Adult Intake Form

The information you provide on this intake form is STRICTLY CONFIDENTIAL and will not be used to inform any criminal activity. It is important that you answer the questions below honestly in order that your therapist can tailor your care appropriately. We can assure you that your therapist will not judge you based on your responses, but will use them to understand your life, and provide you the highest level of care.

When completing each section, some elements may have a (?) which means you can expand the questions to gain additional information.

    Personal Details:

    If you are currently experiencing a moment of crisis, please consider calling Breathing Space on 0800 83 85 87, the Samaritans on 116 123 or NHS24 on 111 for immediate assistance. Or if you feel that there is significant risk please dial 999 and seek help from the emergency operator

    Do you have any children under the age of 16 living with you or in your care?

    What types of alcohol do you drink and how often:

    Do you drink tea/Coffee or high caffeine drinks?

    Do you smoke?

    Do you take any non-prescribed or recreational drugs?

    Have You Ever Attempted to Self-Harm? (?)

    Do You Currently Feel Suicidal?

    Have You ever Attempted to Complete Suicide?

    Do you currently have a plan to end your life?

    Do you have any additional needs? (?)

    Emergency Contact or Next of Kin: (Required Field)

    GP Details (Required Field)

    Is there any family history of psychiatric or mental health issues?:

    We always encourage questions. If you have any specific questions which you’d like to ask about this intake form or therapy in general, please note these below, and your therapist with gladly discuss these in your initial consultation:

    Verified by MonsterInsights