New Client Details

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Personal Details

Name

Date of Birth

Email address

Address

Postcode

Preferred Contact Number

Can i leave a message on this number ?

Yes No

Mobile / Landline

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Can i text message you on this number ?

Yes No

Secondary Contact Number

Can i leave a message on this number ?

Yes No

Mobile / Landline

Image

Can i text message you on this number ?

Yes No

Emergency Contact

This is in the event that something happens to you during our session. Where possible i will discuss this with you prior to making contact.

Name

Relationship to you

Contact Phone Number

Details of GP

This is in the event that something happens that requires me to contact your GP. Where possible, i will discuss this with you prior to making contact

GP Name

Address

Postcode

Contact Phone Number

Type of Therapy Interested in

Please indicate which of the following options you are intersted in:

Face - to - Face, In Person Therapy

Online, Video Therapy

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Please indicate which devices you regularly use

Laptop

Desktop

Smart Phone

Tablet

Please indicate which devices you regularly use

Windows

Android

Mac OS

IOS

Linux

IPADOS

Other

Please say something about why you are requesting online therapy

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Do you have any medical or psychiatric history that i should know about ?

Are you receiving any ongoing treatment that i should know about ?

Please give details of any previous counselling or psychotherapy:

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0330 223 6500, 07429 546 663
www.mattbrookscounselling.co.uk

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