Intake form General information: Name:* Phone number* Mobile phone number Date of birth:* -Day -MonthYearDate E-mail:* example@example.com Preferred name Pronouns National Insurance Number* NHS number* *May be useful if I need to contact your GP, optional to provide. Address Address* Street Address Street Address Line 2 CityState / Province Postal / Zip Code Back Next Please indicate your emergency contact (name, relationship, e-mail and number) This information will only be used in emergencies and providing it is optional. GP surgery name and address * I will not contact your GP without your consent (unless your life is in danger, see safeguarding policy). Please, always provide this information. Back Next The following questions are about your mental health and previous experience with therapy. Answer whichever you feel comfortable answering Have you ever had therapy before? What brings you to therapy now? Are you currently taking any medication? Do you have a current diagnosis or mental health concern you'd like me to know about? Back Next Preferences Do you have any access needs, sensory preferences, or ways of communicating you'd like me to be aware of? Would you like me to check in more, talk less, or give space for silences? Is there anything else you'd like me to know to help make sessions feel safer or more comfortable? Thank you for taking the time to fill in this form. We can always revisit your answers. We will go over this document and your therapy contract during our first session. Submit Should be Empty: