Signup Form - Adult

Initial Psychotherapy Consultation Form
Strictly Private & 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 BACP, CNHC, EMDR Association UK & Ireland (Eye Movement Desensitisation and Reprocessing) and & ILM (Institute of Leadership and Management) 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 anytime, 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 maybe 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
Full name*
Address*
Street Address
Street Address Line 2
City/TownCounty
Postcode
Email*
example@example.com
Marital Status*
Children (Please list all, including step children and all their ages & genders)*
Phone number
Is your phone number confidential?*
Can I leave a voicemail on this number?*
Age*
Date of Birth*
DayMonthYear
Date
GP Name*
GP telephone number*
GP Surgery address*
Street Address
Street Address Line 2
Town/CityCounty
Postcode

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.
EpilepsyHeart AttackStrokeCancerDiabetesAsthmaIBSOther
Details of the above*
Medication*
Please provide details.
General Health*
Please provide details.
Depression*
Please provide details.
Anxiety*
Please provide details.
Alcohol - Units per week*
Smoking including recreational drugs*
Please provide details
Do you exercise regularly?*
What exercise and how often?*
Please provide details

Presenting Issues (areas of concern)
What are the MAIN issues you would like to explore in therapy?*
When did the issues start and how long have they lasted?*
What is the cause of the symptom(s) and does it get worse in a particular situation?*
What is the biggest problem for you?*
What is the worse thing about the situation?*
Please state if you would like to discuss; suicidal thoughts and/or self harming*
When was the last time & is anyone aware of these issues?
Is there anything else in your life you would like to change?*
What do you MOST like about yourself and explain WHY (and the reasons are...)?*
At least 3 things.
What do you LEAST like about yourself and explain WHY (and the reasons are...)?*
At least 3 things.
Does anyone in your family suffer from the same symptoms?*
How well do you sleep? What is your sleep pattern? Any sleep issues? How many hours sleep do you get?*
Have you sought help before? *
When and what help was it? Please outline the kind of therapy sought and received.*
What happened?*
Please provide full details.
Why not?*
What is the worst thing about your situation?*
What is the biggest problem for you?*
Emotional | Financial | Health
Why did you decide to contact me?*
What do you want to achieve by coming to me?*
What are your expectations with coming to therapy?’*
How did you hear about me?*
Please give the referring person's name, if happy to do so.*

General Demeanour
Is Family Life happy?*
Please provide details.
Previous Relationships*
Reason for break-up
Death of loved ones*
Please provide details
Pets*
Hobbies*
How would close friends and family describe you?*
How would colleagues at work (not anyone close) describe you?*
Any other issues / concerns / things you want to be raised?

	Please tick
ADHD	86
ASD (Autism Spectrum Disorder)	87
Addictions	88
Alcohol Addiction	89
Anger Management	90
Anxiety	91
Assertiveness	92
Behavioural Difficulties	93
Bereavement	94
Cancer / Life Changing Condition	95
Career Coaching	96
Cheating and betrayal	97
Coaching	98
Confidence Building	99
Counselling	100
Depression	101
Domestic Abuse	102
Drug Addiction	103
EMDR	104
Executive Coaching	105
Exercising	106
Family Relationship Management	107
Family issues as a result of Severe Anxiety / Severe Depression issues	108
Generalised Anxiety	109
Gratefulness	110
Grief and Loss	111
Harming others	112
Health Anxieties	113
Hypnosis / Hypnotherapy	114
IBS	115
Jealousy issues	116
Life Coaching	117
Loss and Grief	118
Loss and Grief of a pet	119
Meditation	120
Mindfulness	121
Motivation	122
NLP	123
OCD	124
OCD Rituals	125
OCD Thoughts	126
Overcoming Negative Self Talk	127
Pain Management	128
Panic Attacks	129
Parenting	130
Parenting help	131
Phobias	132
Physical Abuse	133
Post Natal Depression (PND)	134
Post-Traumatic Stress Disorder (PTSD)	135
Procrastination	136
Redundancy	137
Relationship Coaching	138
Self Esteem	139
Self-Harm	140
Separation	141
Sexual Abuse	142
Smoking Addiction	143
Social Anxiety	144
Stress	145
Suicidal thoughts	146
Weight Reduction	147

Terms & Conditions
The following Terms and Conditions are outlined below in accordance with the British Association for Counselling and Psychotherapy (BACP) and Complementary and Natural Healthcare Council (CNHC) for you (the client) to read and understand to reduce the risk of client uncertainty and misunderstanding, together with protecting both parties and maintaining best practice at all times.
Should you be in agreement, please sign below and retain a copy for your records.

Confidentiality, Good Practice and Etiquette
In accordance with BACP, CNHC, EMDR Association UK & Ireland (Eye Movement Desensitisation and Reprocessing) and & ILM (Institute of Leadership and Management) 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 anytime, and will not tolerate any abuse albeit verbal or physical at any time.
Clinic and Practice Hours (By appointment only)
Monday – Thursday: 9am – 9.30pm
Friday: 11.30am – 6pm
Saturday: 9am – 5pm
Sundays and Bank Holidays - CLOSED
FaceTime and telephone sessions also available within the above practice hours.
Session Times
Adult sessions: 60 minutes. EMDR sessions: 75-90 minutes
Child sessions: 50 minutes. EMDR sessions: 60-75 minutes
Family Therapy and Couple Therapy session: 90 minutes
Parent & Child Review Sessions: 75minutes
Session times may run over, to which there will always be a charge, unless pre-arranged. If sessions frequently run over or wish to be extended for future appointments, this time must be pre-booked for any future appointment. Session times start at the booked time and not on client’s arrival.
Cancellation Policy
If you need to cancel, unable to attend or keep your appointment or change your mind for whatever reason, I must be informed 48 hours before your appointment (not including Sundays & Bank Holidays), otherwise you will be charged the full hourly charge for the cancelled session.
It is always your responsibility to ensure you receive an acknowledgment from me of your cancellation otherwise you will be charged the full fee for Late Cancellation. This applies if you forget or just DNA (do not attend).
If you cancel a session without the required notice for whatever reason (i.e. snow, illness, delayed train or transport, traffic, school performances, childcare or child illness etc) and you do not settle your invoice within 24 hours of the cancellation, you will always be required to pay upfront for any future sessions that you book. There are no exceptions.
Payment
Payment by the client or bill payer is accepted by the following methods: bank transfer or cash. Payment is always due before any booked session. Failure to do so may result in session being cancelled. In the unfortunate event of a late payment, additional fees will apply.
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 maybe 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.
Please sign*
Clear
Should be Empty:

	Not bothered 0	Mildly, it did not bother me much 1	Moderately, it was unpleasant but I could stand it 2	Severely, I could barely stand it 3
Numbness or tingling
Feeling hot
Wobbliness in legs
Unable to relax
Fear of the worst happening
Dizzy or light-headed
Heart pounding or racing
Unsteady
Terrified
Nervous
Feeling of choking
Hands trembling
Shaky
Fear of losing control
Difficulty breathing
Fear of dying
Scared
Indigestion or discomfort in abdomen
Faint
Face flushed
Sweating (not due to heat)