Client Information Form

CLIENT INFORMATION FORM

Please try to complete as much of this Information Form as possible. Answers are required for anything marked with a red asterisk. The other questions, whilst not required, are an opportunity for you to give me as much information as you are willing to give prior to our first session.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

GP Name and Surgery Details *

Is there any risk that you might harm yourself *

Yes No

Please note that this service is not a crisis service. If you urgently need support, please contact:
   • Samaritans: 116 123 (if you urgently need to talk to someone).
   • Your local A&E or dial 999 (if you urgently need to take action).

You can also contact your local mental health support or crisis line:
   • Northern Ireland: Lifeline - 0808 808 8000
   • Scotland: Breathing Space - 0800 83 85 87, or dial 111 and choose option 2
   • England and Wales: Find an urgent mental health helpline, or dial 111 and choose option 2.

How Did You Find Me? *

What is your presenting problem? What are you struggling with in the here and now? What has prompted you to seek support? *

Onset and problem history- when did this/these problem(s) start? What's the background? *

What are you seeking help now? What are the impacts you are experiencing? *

What is your previous experience of therapy? What modalities (types) have you experienced? how long ago was this? Did that therapy help you to meet your goals at the time? *

Are you currently working with any other mental health professional service or related organisation, such as a Psychologist or Psychiatrist, or perhaps a Social Worker or Probation Officer? Are you currently in group, family or couples therapy? If so, please give details and confirm whether or not you give permission for me to contact them. *

Who Did you grow up with? Tell me about your childhood and your family dynamics. *

Would you say you have experienced any traumatic experiences in your childhood, or your life generally? *

Are you currently taking (or prescribed but not taking) psychological medication? If so, what dosage(s) and how does it affect you? *

Any historical use of psychological medication? If so, please list. *

Any recreational drug use or alcohol use currently, or historically? *

What is your current living situation? Who do you live with? If you are a care-giver to children or dependents, what are their ages? *

Are you currently employed? If so, what do you do? Full or part-time? *

How would you describe your current support system? Who do you talk to, rely on? *

What sustains you or helps you cope with life? This could include hobbies, friends/family or holidays etc. *

What would be a good outcome for you at the end of your therapeutic process? What are you trying to achieve? How would you know things have improved? *

What is your availability to attend sessions please? Please give as many options as possible. *

Which session format(s) would you prefer? *

Online Video Session Telephone Session (no video) 'Walk & Talk' in Tonbridge, Kent Email Sessions

Consent and confidentiality: To protect your confidentiality, the information that you share with this service is held in a way that complies with GDPR and is only accessible by this service. Your record has to be kept for 5 years after which it will be deleted.

Please be aware that if you choose to pay via BACS/cheque/PayPal POS your name will appear on the service bank statement. Your name will be visible to our accountancy service but they have no access to information regarding your counselling sessions and are committed to maintaining your confidentiality.

By completing this form you are consenting that information can be shared about you with third parties if any immediate risk of harm to self or others is identified, or if we are compelled to do so by a court.

Please indicate your agreement for Craig Kerrecoe Psychotherapy & Counselling to use your contact details for the purposes of delivering you a responsive psychotherapeutic counselling service. *

I agree

Submit

Craig Kerrecoe MNCPS (Acc.)

CLIENT INFORMATION FORM

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