Intake Form

Client Information Form

Now that you have read, signed and returned the counselling agreement, the next stage is for you complete the form below. The information your provide here is safe, secure and will be treated as confidential. If you have any trouble completing this, please email me at jannelle@yellowtreewellness.co.uk

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Thank you, your form has been received. Please contact me if you have any questions or something to add.

New Client Intake Form

Please note that you will need to complete this form in one attempt, you are unable to save and return to complete it later.

First Name

Last Name

Date of Birth (DD/MM/YYYY)

Where did you hear about working with Jannelle?

Contact Details

Mobile Number

Email Address

Home Address

What is your current accommodation status

Medical Information

Please provide the name and address of your GP

Are you taking any prescribed medication to support your mental health?

If Yes, please specify

Do you have a history of an attempt /attempts to harm yourself? (required)

Yes

Do you have a history of an attempt / attempts to end your life? (required)

Yes

If you answered “Yes” to any other the above, please share which and the last time below

Relationships

Please provide the name and relation for your next of kin (only to be contacted in the case of an emergency)

Please provide a contact number for your next of kin

Are you a carer for anyone under the age of 18 or vulnerable adult?

If Yes, please specify the age and relation

Therapy

Have you worked with a Therapist or Counsellor / Psychologist / Coach before? (If yes, please state which, when, where and for how long)

Please provide a brief summary of what brings you to seek therapy now?

Please note below anything not prompted above, which you feel important to share?

Phone

Jannelle Johnson

Trauma Therapist & Accredited Personal Performance Coach

Yellow Tree Wellness Ltd