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71 Vyse Street, Jewellery Quarter, B18 6EX
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Individual Form
Please read this form before completing. We request this is completed 24 hours before your session, which allows us to prepare for your session however If you feel uncomfortable filling out this form - please fill out this alternative form instead:
click here
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Date
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DD slash MM slash YYYY
Name
(Required)
First
Last
Date of birth
(Required)
Phone
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Address
(Required)
Street Address
Address Line 2
City
ZIP / Postal Code
Email
(Required)
Therapist name
(Required)
Kiran (Kay)
Mehmoona Ashiq
Jaspreet Dhanda
G.P. Phone number
(Required)
G.P. Address
(Required)
Street Address
Address Line 2
City
ZIP / Postal Code
Do you have a disability?
(Required)
Yes
No
If so can you please describe how this affects your life and tell us if you have any special needs regarding psychotherapy.
(Required)
Your issues. Please describe the nature of your difficulties, how long you have had them, how you think they began and how they affect your life at present.
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In what ways do you hope that treatment such as, if appropriate, counselling or therapy could help you?
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Have you ever sought help for emotional or psychological difficulties before?
(Required)
Yes
No
If so, please give details: helped by GP, counselling or psychotherapy, referred to psychiatrist, hospitalised, etc.?
(Required)
Has any other member of your family had help for psychological difficulties (please give details as far as you know them).
(Required)
Yes
No
Trigger warning. Have you ever made a suicide attempt/suicidal thoughts or self harm?
(Required)
Yes
No
If you've anwsered yes above, please could you give some details about when this occurred?
(Required)
Are you on any medication at present for emotional/psychological difficulties, if so, please list these?
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Is there any concern about your drinking or issues with non prescribed/prescribed drugs?
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Have you ever had issues with eating?
Yes
No
Please give details below
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Do you have any difficulties with your body? The way you feel about it and the way you think it looks?
(Required)
Are you experiencing problems in relationships?
(Required)
Yes
No
Coping: How do you cope with situations?
(Required)
How easy do you find it to recognise your own thoughts?
(Required)
List any things you can change to help yourself:
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Is there anything you’ve tried which have worked for you?
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Mother: Please describe your relationship.
Father: Please describe your relationship.
Siblings: Please describe your relationship(s).
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What was the general atmosphere like at home, including how your parents got on with each other?
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Were there any important changes, for example, moves or any other significant events, during childhood? Including any separations from the family or parental divorce. Please give approximate ages and details.
(Required)
What was your experience of school like?
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The terms and conditions and contract is specifically between the therapist carrying out the therapy and the client.
To view our terms & conditions,
click here
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Consent
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I confirm I have read and agree with the terms & conditions on the link above and the information I have provided is accurate.