• Initial Psychotherapy Consultation Form
    Strictly Private and Confidential and non-judgmental.

    • It is important to complete this form as much as possible PRIOR to the session so that no time is wasted within the session.
    • Only complete as much as you feel / want / you are able to.
    • All information will be kept strictly private and confidential, within your file and used only for your purposes only.
    • No information will be given to any 3rd party under any circumstances.

    Confidentiality, Good Practice and Etiquette

    • In accordance with the BACP, the EMDR Association UK & Ireland (Eye Movement Desensitisation and Reprocessing) the ILM (Institute of Leadership and Management) and the CNHC all sessions are always strictly confidential and non-judgemental.
    • In accordance with the above Guidelines’ and Codes of Conduct, the boundaries between both Counsellor/Therapist and client, together with a professional relationship, must always be adhered to.
    • The Counsellor/Therapist gives the right to refuse a session, terminate future sessions or remove clients from the clinic at any-time, and will not tolerate any abuse albeit verbal or physical at any time.

    Files and Third Party

    • I will at all times adhere to the GDPR Regulations. However, written consent from the client is always required before any information and/or details be divulged to any third party, other than a Solicitor/Law Partnership.
    • Files may be obtained by clients once therapy has ended at a charge of £10 plus P&P, payable prior to release.
    • Reports and/or letters for insurance, court purposes etc will be charged for at an hourly rate, which is payable in advance. This will be discussed beforehand and confirmed.

  • Personal Details

  • Date of Birth*
     / /

  • Medical History

    Please tick all that are applicable and provide adequate details.     

    IMPORTANT - Please note that in some instances - a medical consent letter may be required from your GP or Consultant for some conditions before any sessions can commence.

  • Employment Details

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  • Presenting Issues (areas of concern)

  • Rows

  • General Demeanour

  • The Beck Anxiety Inventory

  • Below is a list of common symptoms of anxiety.  Please read carefully and only indicate (if you have been bothered) how much you have been bothered by each symptom in the last week including today. Place a tick in the space next to each symptom.

  • Rows
  • The Beck Depression Inventory

  • Please read each statement CAREFULLY before answering.

    Pick one in each group which best describes YOU and the way YOU have been feeling in the past week, including today.

    If several statements in the group apply, please select the ONE you feel most applies.

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  • Terms & Conditions

  • By signing this form you are in effect, agreeing to my business’ T&Cs which are clearly outlined in the letter that I have emailed to you and which you must read and understand. Part of these terms concern the 48 hour cancellation notice as well as pre-payment for any sessions you book. You are also agreeing to comply with the ‘Ground Rules of Therapy’ – again which is clearly outlined in the document that was emailed to you. I will from time to time update this document as I feel necessary. A copy will be kept in your file. You also acknowledge that you are complying with any Government Regulations surrounding Covid-19 and with the ‘Covid-19 Risk Assessment’ which I have emailed to you.

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