New Client Form Contact us by filling out the form below. About You1 of 3Separator1First NameLast NameContact NumberDate of BirthEmailAddress 1Address 2Town / CityCountyPostcodeGenderMaleFemaleThird Gender / Non BinaryRelationshipSingleLiving with Partner / MarriedSplitter1Your Medical History2 of 3Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?YesNoAre you currently taking any prescription medication? (if yes please bring a note of what you are taking and in what doses to your next session)YesNoHave you ever been prescribed psychiatric medication?YesNoIf yes please list belowSeparator2Please answer the followingHow would you rate your physical health?PoorAverageGoodHow would you rate your quality of sleep?PoorAverageGoodHow would you describe your general mood?PoorAverageGoodHow would your exercise routine?PoorAverageGoodDo you eat regular meals?YesNoDo you experience any panic attacks or phobias?YesNoDo you feel you have a problem with alcohol?YesNoDo you feel you have a problem with drugs?YesNoIs there anything you would like to add?Splitter2Family3 of 3Please list all members of your immediate family below and include their age and your relationship to them is either – Mum, Dad, Brother, Sister, Aunt, Uncle, Cousin etc.Additional InformationAre you currently employed?YesNoAre you happy with your current employment situation?YesNoDo you consider yourself to be spiritual or religious?YesNoDid you enjoy school?YesNoWho did you talk to or what did you do when you were a child and needed advice?Please list an emergency contact for you.Emergency Contact NameEmergency Contact NumberSeparator3I confirm that I am happy for this information to be passed to Dan Alway*YesSend Error occured. Please confirm your data and submit again:
