Adult Intake Form The information you provide on this intake form is STRICTLY CONFIDENTIAL. Please enable JavaScript in your browser to complete this form.First NameSurname:DOB:Address:Town/City:Postcode:Mobile Contact Number:Home Contact Number:Email Address: *Is it okay to:TextCallEmailIn order to contact you and to arrange a consultation and for future contact, please confirm the means by which we are allowed to contact you.What is your reason for seeking Therapy:Please provide an insight why you have chosen to seek therapy at this time.What are the symptoms which lead you to seek Therapy?Stress, anger, sleep problems, impotence, headaches, sexual disfunction, ocd, bad habits.Do you have any official diagnosed conditions by a medical professional and when were you diagnosed?Depression, anxiety, bipolar, heart condition, cancer, asthma, diabetes.Please provide information on any past or present medication including dosage:If you could specify UP TO THREE GOALS, you wanted to achieve through therapy what would they be?Do you have any additional needs?YesNoEmergency Contact Name or Next of Kin: (Required Field)Relationship:First name:Surname:Address:Postcode:Mobile Contact Number:Home Contact Number:GP Details - GP’s Name: (Required Field)GP’s Practice Name:Address:Postcode:Telephone Number:Are you currently receiving support from any other professionals -Community Mental HealthPsychiatristPsychologistAddiction ServicesSocial WorkConfirmationI acknowledge that this information will be held in strict confidence by Dynamic Diamond, and that they will store this provided information in accordance with current GDPD laws and regulations. I give Dynamic Diamond permission to contact me regarding this intake form to arrange a consultation and future therapy sessions. I understand that my therapist may be required to share information with my GP or other listed agencies/professionals involved in my care. For this purpose, I provide permission for my Dynamic Diamond therapist to make such contact. I understand that my confidentiality will be respected at all times, but that my therapist can break confidentiality if I am at risk of harming myself; others or if there is any issues concerning child protection/welfare.DateWebsiteSubmit