Client Information Form This form is required to be completed before our initial assessment sessionPlease enable JavaScript in your browser to complete this form.Full Name *Date of Birth (DD/MM/YYYY) *Address *Telephone Number *Email *Are you a student? (proof will need to be provided to receive the discounted fee) *YesNoWhen necessary (for example, for appointments) is it okay for Time to Grow Counselling and Psychotherapy to *Phone you?Text you?Leave a message?Write to you?Emergency Contact Name (and relationship to you) *Emergency Contact Address *Emergency Contact Telephone Number *GP NameGP Surgery Address *GP Surgery Telephone Number *If you care for children under 18, please list their ages below (please type '0' if this doesn't apply) *Have you been diagnosed with a mental health problem before? *YesNoI believe I may have a mental health problem, but it has not been officially diagnosedIf you answered anything other than 'No' to the above question, can you please provide further information belowAre you currently taking any medication for mental health/psychological problems? *YesNoYes, but it is unprescribedIf you answered anything other than 'No' to the above question, can you please provide further information belowDo you have Social Worker/Involvement with Social Services? *YesNoIn the past, but the case is closedIf you answered anything other than 'No' to the above question, can you please provide further information below (including name(s)/contact details of Social Worker(s) if applicable)Can you briefly describe your problem, and what you are hoping to gain from therapy? *I confirm I have read and understood the Privacy Policy *YesYou will have received a copy via email, or you can read it here: Privacy PolicyWebsiteSubmit