Intake form Name * First Name Last Name Pronouns She/her He/him They/them Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country GP Name & Address * Emergency Contact Name * First Name Last Name Emergency Contact Number * (###) ### #### Are you involved in any legal proceedings? * Yes No Are you currently taking any medication? * If so, please provide further detail below Do you have any previous psychiatric history? * If yes, please provide further details below Have you ever or are you currently experiencing suicidal ideation or attempts? * What are you hoping to explore or work on in counselling? * How did you hear about me? Counselling Directory Search engine Word of mouth Social media Other Thank you for these details.Your information has been submitted securely and is handled in line with UK GDPR. I am registered with the Information Commissioner’s Office and keep your data confidential, secure, and used only for the purposes of our work together.
