Client Information Form &dash; Time to Grow Counselling and Psychotherapy

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) *

Yes
No

When 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 Name

GP 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? *

Yes
No
I believe I may have a mental health problem, but it has not been officially diagnosed

If you answered anything other than 'No' to the above question, can you please provide further information below

Are you currently taking any medication for mental health/psychological problems? *

Yes
No
Yes, but it is unprescribed

If you answered anything other than 'No' to the above question, can you please provide further information below

Do you have Social Worker/Involvement with Social Services? *

Yes
No
In the past, but the case is closed

If 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 *

Yes

You will have received a copy via email, or you can read it here: Privacy Policy