Therapy Health Questionnaire | Dr Jack Psychology

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Questionnaire

Please fill out the following form to help me ensure that I am the best person to help you

Full Name

Address

Email Address

Date of Birth

Please tell me about you or your child's difficulties and what you are hoping to gain from therapy. Please include brief details of any previous theray received.

Have you or the child for whom you are seeking help, self-harmed or seriously thought about ending your life in the past 12 months? *

No

Yes

Have you been hospitalized in the last 12 months? *

No

Yes

If you answered yes to either of the above questions, please elaborate

Name and address of General Practitioner and emergency contact

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

If you require immediate help or assistance please contact your GP, out of hours NHS services on 111 or emergency services on 999. I am unable to offer crisis support. I receive multiple emails per day and may not be able to respond to every enquiry.

Get in touch - Catriona@drjackpsychology.com

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