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My Details

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Forename
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DOB
Age
National Identity
City
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Disability
Long-term Condition
Email Address
Telephone number

Relationships & Support

Living AloneLiving with partnerLiving with parents/guardiansLiving with friends/relativesLiving in shared accommodationLiving in institution/hospitalLiving in temporary accommodation(hostel)Carring for children under5Carring for children over5

Employment

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Information for Therapy

What is the problem you are seeking help with?

What is your understanding of how and when your problem developed?

How long have you had this problem?

How does your problem affect you?

Do you consider yourself to be at risk from self-harm or suicide?

Please specify any medication currently prescribed to help you with the above problems:

What are your expectations and goals of therapy?

Have you ever had therapy? If yes, please specify what kind, when did you had it and what problem / aspect of the problem was treated.

What is your availability during the week?

How did you hear about our services (Instagram, Facebook, Leaflet, Word of Mouth etc.) ?

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By clicking ‘’Send’’ you are requesting to be contacted by us to discuss psychological treatment in accordance with our privacy policy.