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Manor Road, Chatham
wendy@coachhouseinspired.com
07530 978620
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Enter your full name
Date of birth
Todays Date
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What is your PostCode
Gender
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Relationship Status
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Reason for Seeking Therapy
Please check any conditions or diagnoses you have or have had in the past:
Anxiety
Depression
Bipolar Disorder
PTSD
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Eating Disorders
Substance Abuse
Personality Disorders
Sleep Disorders
Chronic Pain Conditions
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Have you previously attended therapy or counseling?
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Please list any medications you are currently taking and their dosages:
Please check any symptoms you are currently experiencing:
Mood Swings
Sleep Problems
Panic Attacks
Social Isolation
Self-Harm Urges
Irritability or Anger
Difficulty Concentrating
Racing Thoughts
I understand that all information shared during therapy sessions will be kept confidential, with certain exceptions as required by law. I have read and understood the therapist's confidentiality policy.
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