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Little Big Minds – Pre-Chat Intake
This short form helps me understand what you need so I can support you well. It’s not a crisis service. If you’re in immediat danger, call 999. For urgent support, contact Samaritans 116 123 (24/7) or text SHOUT to 85258 (UK) 
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Email *
Section A
Consent & Ground Rules- If you’re under 18, I’ll need parent/guardian consent before support starts.

I understand Little Big Minds offers wellbeing support and guidance, not emergency care or medical diagnosis.  *
Required
Information is private except if there is a concern about risk of harm to you/others or a legal duty to share. *
Required
I consent to Little Big Minds storing and using my information to provide support, per the Privacy Notice https://www.littlebigminds.uk/privacy *
Required
How may I contact you about your enquiry? (choose at least one) *
Required
If there is a serious concern for your safety, may I contact your emergency contact and/or your GP? *
Are you 18 or over?  (Required) *
If you are under 18, fill in the next section. Otherwise skip to Section B
Parent/Guardian full name
Relationship
Parent/Guardian email or phone
Parent/Guardian consent
Section B
About You
Full name (preferred name) *
Email - We’ll use this to follow up. Double-check for typos *
Phone (optional)
Best way to contact you *
Town/Region
Accessibility needs or preferences (e.g., no video, captions, slower pace)
Section C
What brings you here
In your own words, what do you want help with right now? *
How long has this been a difficulty? *
How is it affecting day-to-day life (work/study, sleep, relationships)?
What would feel like a “good outcome” from our chats?
Section D
Safety & Risk Check-In
Right now, how safe do you feel? *
In the past month, have you had thoughts of harming yourself or ending your life? *
Any recent self-harm, attempt, or plans? *
If yes, and you’re comfortable, add any detail here (optional)
Anything that helps you stay safe (people, routines, pets)?
Emergency contact (Name / Relationship / Phone / Email) *
GP details (Practice name / GP name if known / Phone)
Section E
Supports & Background
Any mental health diagnoses (optional)
Medications or therapies you’re using (optional)
Are you on any waiting lists (e.g., ADHD/autism assessment, counselling)?
Clear selection
Waiting list details (optional)
Anyone else currently involved (school, social worker, CAMHS/CMHT, charity)?
Section F
Practicalities & Preferences
Preferred chat format *
Camera comfort *
Session length you prefer *
Communication preferences (tone, pace, triggers to avoid)
Section G
Optional Demographics
Age range
Clear selection
How did you hear about Little Big Minds?
Clear selection
I confirm the information I’ve provided is accurate to the best of my knowledge and I’m completing this form for myself (or I am the parent/guardian giving consent). *
Signature (type your name) *
Date *
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