Adult Personal Details Intake Form

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:

First Name:

Surname:

Nick Name or Preferred Greeting:

DOB:

Address:

Postcode:

Mobile Contact Number:

Home Contact Number:

Email Address:

Is it okay to: (?)

TextCallEmail

Employment Status.

Profession: (?)

What school/Uni/College do you attend:

What do you currently study at Uni/College:

Religion (Optional): (?)

Culture (Optional): (?)

Gender (Optional): (?)

Sexuality (Optional): (?)

What are your hobbies: (?)

Who or what would you consider to be your support mechanisms: (?)

Do you feel safe at home?: (?)

YesNo

If no, please provide a brief description

Are you in danger of being harmed by anyone else?

YesNo

If yes, please provide a brief description

Are you in any kind of crisis at the moment where you may want to harm yourself or anyone else?

YesNo

If yes, please provide a brief description

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?

YesNo

First Name:

Second Name:

Date of Birth:

Address: (please specify if different to you listed home address above)

Postcode:

School/Nursery:

Main carer: (?)

Services Involved: (?)

Is anyone else currently involve in your care?: (?)

YesNo

If Yes:

Service:

Name:

Address:

Telephone Number:

Reason for involvement:

Permission to contact:

YesNo

Do you have any Criminal Convictions?:

YesNo

If Yes:

Type of Conviction:

Brief description of offence:

Year of Conviction:

Court:

Sentence:

What is your reason for seeking Therapy: (?)

If you could specify UP TO THREE GOALS, you wanted to achieve through therapy what would they be?

What are the symptoms which lead you to seek Therapy?: (?)

Do you have any official diagnosed conditions by a medical professional?: (?)

Do you suffer any non-diagnosed medical complaint?:

Have you suffered any serious accidents?: (?)

YesNo

If yes, please provide a brief description

Please provide information on any past or present medication including dosage: (?)

What Type of Alcohol Drinker are you?:

Do you consider yourself to have a drink problem?:

What types of alcohol do you drink and how often:

Type

Unit

Quantity

Frequency

Do you drink tea/Coffee or high caffeine drinks?

Type

Unit

Quantity

Frequency

Do you smoke?

YesNo

Type

Quantity

Frequency

Do you take any non-prescribed or recreational drugs?

YesNo

Type

Quantity

Frequency

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

YesNo

Describe If yes:

Do You Currently Feel Suicidal?

YesNo

Have You ever Attempted to Complete Suicide?

YesNo

Type of Attempt

Date

Intervention Received

Do you currently have a plan to end your life?

YesNo

Describe If yes:

Do you have any additional needs? (?)

Emergency Contact or Next of Kin: (Required Field)

Relationship:

First name:

Surname:

Address:

Postcode:

Mobile Contact Number:

Home Contact Number:

GP Details (Required Field)

GP’s Name:

GP’s Practice Name:

Address:

Postcode:

Telephone Number:

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

YesNo

Please provide a brief description

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:

I confirm that the information supplied is a true and honest response to the questions asked. I understand that providing false or misleading information can interfere with the treatment provided via therapy and may delay improvements in my health. I acknowledge that this information will be held in strict confidence by Empathy Rooms Ltd, and that they will store this provided information in accordance with current GDPD laws and regulations. I give empathy rooms permission to contact me regarding this intake form to arrange a consultation and future therapy sessions. I understand that my therapist may be required to share information with my GP or other listed agencies/professionals involved in my care. For this purpose, I provide permission for my Empathy Rooms Ltd therapist to make such contact. I understand that my confidentiality will be respected at all times, but that my therapist can break confidentiality if I am at risk of harming myself; others or if there is any issues concerning child protection/welfare.

Name:

Signature:

Date: