Patient Information

Name

Preferred Name

Address

Phone Number

Date of Birth

Email Address

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Ethnicity

Marital Status

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If Married, how long have you been with your partner?

Anyone else living with you?

GP

GP Surgery Address

Payment

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If medical insurance, please add policy number, authorisation code and name on policy

Highest Level of Education 

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If Other please specify

Current Employment (Select all that apply)

If Other please specify

Occupation

Current Residence

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Patient History

Have you ever seen a therapist/psychiatrist/psychologist before and if so, when and what were your symptoms?

When did you last visit your GP and what were your symptoms?

Have you ever been treated for any psychological difficulties? If yes, please state

Have you ever been hospitalized in a psychiatric facility? If yes, please describe and include duration

Have you ever attempted to harm or kill yourself? If yes, please state date and method of attempt

Please list all current medications below (including birth control pills, over the counter medications and herbal remedies)

Family History