RESPECT COUNSELLING THERAPY ADMISSION FORM – CONFIDENTIAL.

 

Name
Hospital No.
Address
Age
Date of Birth
Religion
Telephone
G.P Name
Address
Would you prefer a male counsellor or female counsellor Male or Female
Domestic circumstances
Employment history
Past experience hypno/psycho related
Presenting problem
Medication
Therapy Indicated
Please answer the following, have you ever had:
Answer Yes No Details if you answered yes
Hypnotherapy, Psychotherapy or Counselling
Heart trouble
Migraine
Epilepsy
Hay Fever or other Allergy
E.C.T.
Arthritis
Depression
Any Specific Fears
Do you wear contact lenses
Declaration

I suffer from

And this condition has previously been diagnosed by medical personnel.

The information given above and throughout this consultation is to the best of my knowledge full and correct.

 
   
To be completed at first consultation
Print Name Client
Date Client
Signed Client
     
Witnessed By    
Print Name Counsellor
Date Counsellor
Signed Counsellor