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Patient Information
Name
Preferred Name
Address
Phone Number
Date of Birth
Email Address
Ethnicity
Marital Status
If Married, how long have you been with your partner?
Anyone else living with you?
GP
GP Surgery Address
Payment
If medical insurance, please add policy number, authorisation code and name on policy
Highest Level of Education
If Other please specify
Current Employment (Select all that apply)
If Other please specify
Occupation
Current Residence
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)