Child 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:

    Select all that apply (hold ctrl on your keyboard)

    Select all that apply (hold ctrl on your keyboard)

    If you are currently experiencing a moment of crisis, please consider calling Breathing Space on 0800 83 85 87, the Samaritans on 116 123, Childline on 0800 1111, 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

    Does your child have any children of their own?

    Does your child have any siblings?

    Does your child drink tea/Coffee or high caffeine drinks?

    Does your child smoke?

    Does your child take any non-prescribed or recreational drugs?

    Has Your Child Ever Attempted to Self-Harm? (?)

    Does Your Child Currently Feel Suicidal?

    Has Your Child Ever Attempted to Complete Suicide?

    Does your child 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:

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