Forge Personal Training — Counselling Intake

Personal Details

Tell us a little about yourself.

First Name *

Surname *

Address *

Phone *

Email *

Date of Birth * You can type your date of birth (dd/mm/yyyy) or choose it from the calendar.

GP name & surgery

Emergency contact name

Emergency contact phone

Relationship to you

Presenting Issues

What brings you to therapy today?

Previous therapy or counselling

Mental Health History

Mental health history

Current medication

Risk Assessment

History of self-harm

Yes No

Current or recent suicidal thoughts

Yes No

Substance misuse (current or past)

Yes No

Session Agreement

Data Protection (UK GDPR)

I hereby declare that the details are true and correct to the best of my knowledge and I undertake to inform you of any changes immediately. I have read and acknowledged the Privacy/GDPR policy. Thank you kindly for visiting us today and completing this form. Hope to see you again soon.

Client Signature *

Please sign below.

Date *

Counselling Intake

Personal Details

Presenting Issues

Mental Health History

Risk Assessment

Session Agreement

Data Protection (UK GDPR)

Client Signature *

Age Restriction

Additional Information