Individual Form

Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Email(Required)

Therapist name(Required)

G.P. Phone number(Required)

G.P. Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Age(Required)

Place of birth(Required)

Do you have a disability?(Required)

If so can you please describe how this affects your life and tell us if you have any special needs regarding psychotherapy.(Required)

Could you please give us the following details about your family? Father What is his age now? If he is no longer alive, at what age did he die? Cause of his death How old where you when he died? What is, or was, his occupation?

Mother What is her age now? If she is no longer alive, at what age did she die? Cause of her death How old were you when she died? What is, or was, her occupation?

Details of your brothers and sisters, including yourself: How many children in the family, including yourself? Please also include any step or half-brothers and sisters or any other children adopted by your parents; indicate who they are:(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. You might want to include in this section any issues related to race, class, culture, gender and sexuality that you consider have been factors in your life.(Required)

In what ways do you hope that treatment such as, if appropriate, counselling or therapy could help you?(Required)

What aspects of your life give you satisfaction?(Required)

Have you ever sought help for emotional or psychological difficulties before?(Required)

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)

Have you ever made a suicide attempt?(Required)

If you've anwsered yes above, please could you give some details about when this occurred and what happened?(Required)

Have you ever had thoughts of suicide?(Required)

If you've anwsered yes above, please could you give some details about when this occurred and what happened?(Required)

Are you on any medication at present for emotional/psychological difficulties, if so, please list these?(Required)

Do you have sexual problems?

Is there any concern about your drinking?(Required)

Are you taking, or have you taken, non prescribed drugs of any kind?

Please give details below(Required)

Have you ever deliberately inflicted injury on your body?(Required)

Have you ever had eating problems?

Please give details below(Required)

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)

What do you find satisfies you and/or frustrates you in this relationship?(Required)

Coping How do you cope with situations?(Required)

What strengths do you feel you have in coping with situations?(Required)

How easy do you find it to recognise your own thoughts?(Required)

List any things you can change to help yourself:(Required)

Is there anything you’ve tried which have worked for you?(Required)

Family - Could you give us some further details about your mother – her character or personality, and your relationship with her?(Required)

Family - Please tell us something about your father – his character or personality, and your relationship with him?(Required)

How easy do you find it to say no to your partner?(Required)

Please describe your relationships with your brothers and sisters – whether helpful or problematic for you?(Required)

What was the general atmosphere like at home, including how your parents got on with each other?(Required)

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?(Required)

How do you feel about having been asked to fill in this questionnaire?(Required)

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.

Consent(Required)

I confirm I have read and agree with the terms & conditions on the link above and the information I have provided is accurate.

GET IN TOUCH

71 Vyse Street, Jewellery Quarter, Birmingham, B18 6EX

Email Company

Time Open

We Are Support 24/7