Client Details Form
This form is used to collect your personal details ahead of your initial session. This help me to assess if we would be a suitable fit for working together.
Email *
Name *
Address *
Telephone Number *
Email address *
Date of Birth *
MM
/
DD
/
YYYY
Gender/Identity *
Emergency Contact (Name, Phone  Number & Relationship to you)
What is it that brings you to accessing therapy? Presenting issues or difficulties. *
What are you hoping to gain from therapy? *
Have you had therapy before? *
Medical history/Medications/Diagnosis/Disability
Any current suicidal ideation/self harm? *
Details for above
Any previous suicidal ideation/self harm? *
Details for above
Support Network (family, friends, carers etc) *
Availability for sessions *
Required
Please add your availability below
How did you hear about Lisa Jane's Counselling & Psychotherapy? *
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