Skip to content
Manor Road, Chatham
wendy@coachhouseinspired.com
07530 978620
Facebook
Twitter
Youtube
Linkedin
Home
Services
Blog
Contact
X
Appointment
Referral
Appointment
Referral
Referral
Intake
Form
Please fill out this form.
Enter your full name
Date of birth
Todays Date
Enter your full address
What is your PostCode
Gender
Male
Female
Non-binary
Prefer not to say
Other
Relationship Status
Single
Married
In a relationship
Divorced
Widowed
Separated
Prefer not to say
Occupation
Employer
Emergency Contact Name
Emergency Contact Number
Reason for Seeking Therapy
Please check any conditions or diagnoses you have or have had in the past:
Anxiety
Depression
Bipolar Disorder
PTSD
OCD
ADHD
Eating Disorders
Substance Abuse
Personality Disorders
Sleep Disorders
Chronic Pain Conditions
Other (with a text field to specify)
Have you previously attended therapy or counseling?
Yes
No
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.
I consent digitally
Send
6178
