Appointment

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Client Name *

Email *

Date *

Gender *
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Date of Birth *

Ethnicity

Address *

Phone *

Can I text your mobile? *

Programs *

Emergency contact details: *

Emergency contact telephone: *

GP Name: *

Surgery/Address *

Telephone *

Previous experience of therapy? *

Previous experience of psychiatric support? *

Medical History: *

Genogram/significant people: *

Employed: *

Referred by: *

Date of first session: *

Description of what has brought the client to therapy: *

What do you hope to achieve from therapy/client goals? *

What have you done to cope with their problems and how helpful has this been? *

Are you paying or the charity will pay for your session? *

Name of Charity (if Charity will pay for your session)

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We respect your private information