NAME
EMAIL
TELEPHONE
POSTAL ADDRESS
DATE OF BIRTH
GP PRACTICE ADDRESS
EMERGENCY CONTACT NAME
EMERGENCY CONTACT PHONE NUMBER
REASON FOR SEEKING SUPPORT - PLEASE BRIEFLY OUTLINE THE MAIN DIFFICULTIES/SYMPTOMS YOU ARE EXPERIENCING - THIS COULD BE WITH THOUGHTS, EMOTIONS, MEMORIES, BEHAVIOURS*
HOW LONG HAVE YOU BEEN EXPERIENCING THESE TYPES OF DIFFICULTIES?
HAVE YOU HAVE HAD ANY TREATMENT BEFORE NOW? IF SO PLEASE DESCRIBE WHAT THIS WAS
DO YOU HAVE ANY DIAGNOSED MENTAL HEALTH DIFFICULTIES? IF SO, TELL US WHO GAVE YOU THIS DIAGNOSIS
HAVE YOU SEEN YOUR GP ABOUT YOUR DIFFICULTIES?
PLEASE LET US KNOW IF YOU ARE CURRENTLY TAKING ANY MEDICATIONS, IF YOU HAVE ANY PHYSICAL HEALTH PROBLEMS AND IF YOU HAVE ANY ALLERGIES.
ANY ADDITIONAL INFORMATION?
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