Preferred Pronouns

First Name*

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Surname*

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Date of Birth if under 18*

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Gender

Ethnicity

Sexuality

Any Disabilities

Telephone*

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Email*

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Address*

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GP Surgery Name*

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Emergency Contact Name*

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Emergency Contact Number*

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Any Medications*

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Have you ever or are you currently struggling with a dependency with alcohol or drugs - YES or NO*

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Have you ever or are you currently struggling with any other form of dependency or addiction - YES or NO*

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Have you ever experienced any childhood trauma - YES or NO*

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Have you ever been a victim or witness of domestic violence - YES or NO*

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Anything else you would like to share

I hereby agree that this data will be stored and processed for the purpose of establishing contact. I am aware that I can revoke my consent at any time.*

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SELF REFERRAL FORM

You’ll need to complete this form before your first full session to help us make the most of our time together. It provides important background information, including your reasons for seeking therapy and any safeguarding details I need to be aware of.

If you’d prefer to go through the form during our first session, that’s absolutely fine - just let me know. However, completing it in advance allows us to focus more on you and what you want to work on from the very first session.