Intake form

Cognitive Behavioural Therapy & EMDR

Wiltshire

t: 0777 3714723 | e: hello@rupertcrockett.co.uk

Full Name *

Date of Birth *

Email address *

Mobile number *

Occupation *

Address *

Emergency contact name *

Emergency contact telephone number *

GP name and surgery *

Medical History (if relevant, mental or physical) *

Current Medication *

Reasons for Seeking Therapy *

Goals for therapy: What would you like to resolve after receiving a course of CBT/EMDR ? *

Please list any significant or distressing events such as grief, trauma, accidents, hospitalisations, losing job or relationship problems etc. (age at the time of the event).

Any Other Relevant Information

Cancellation policy

Please note

Since the scheduling of an appointment involves the reservation of time set aside especially for you, a minimum of 24 hours notice is required for rescheduling or cancellation of an appointment. If for any reason a session is cancelled less than 24 hours prior, the full fee will be charged. Please sign below.

Date / Time *

Signature *

Name

Websites for Therapists by: YouCan Consulting