Initial Consultation Form

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Initial Consultation Form

JW Therapy

Email *

Name *

Date of Birth *

YYYY

Phone *

In the event you can't get to the phone, are you happy to receive a voicemail?

Yes

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Address *

Postcode *

Occupation *

GP Name and Address *

Any ongoing health conditions? Please provide details. *

Have you received treatment for this in the past? Please provide details. *

Medication currently prescribed *

Do you think you could be pregnant? *

Yes

Have you received any talk therapies (counselling, hypnotherapy, for any mental health issues in the past? (E.g. Anxiety, Depression, Psychosis, Personality Disorder, etc.)
*

Yes

How would you score the effectiveness of this treatment?

Ineffective

Extremely Effective

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Please explain your answer to the above

Marital Status *

Single

Married

Cohabiting

Separated

Divorced

Shared Accommodation

Other:

Data Protection - Are you happy for your data to be stored electronically and that all handwritten notes will be stored in a locked storage unit when not in use. *

Yes

What has led you to seek therapy? *

How long has this been an issue? *

What was happening in your life at the time that the issues began? Please include details of any major losses, stresses or changes in the last five years.
*

What would you like to achieve as a result of therapy?
*

Are there any times/places where you have felt particularly relaxed? This will help to formulate personalised scripts. *

I have read and understood the contract at https://www.jwtherapy.co.uk/policies/contract-agreement (mandatory) *

Yes

Yes but I have questions about this

Any further details that you feel may helpful for your therapist to be aware of?
*

Send me a copy of my responses.

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