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Psychotherapy Intake Form

This form contains PHQ-9 and GAD-7 self-report questionnaires. Please score each question from a scale of 0 to 3, with the corresponding numbers:

0: Not at all

1: Several Days

2: More than Half the Days

3: Nearly Everyday

I have downloaded and completed the attached PDF and returned by email. Click Here

Are you booking a video appointment or In person session?

Provide details of any psychotropic medications (SSRIs)

Date of Birth

Day

Month

Year

Occupation

Marital Status

What is your Preferred pronoun

How many dependents under 18?

Do you have any Disability?

Provide details of any Neurodivergent condition

Provide details of any Long Term Health Condition (LTC)

Emergency contact Name and Number

GP Name, address, email and phone number

Describe the main problems you are having right now that led you to therapy treatment

Therapeutic goal/outcomes

On a scale of 0 to 3, how often over the past 2 weeks have you had : Little interest or pleasure in doing things?

On a scale of 0 to 3, how often over the past 2 weeks have you : Felt down, depressed, or hopeless?

On a scale of 0 to 3, how often over the past 2 weeks have you had: Trouble falling or staying asleep, or sleeping too much?

On a scale of 0 to 3, how often over the past 2 weeks have you : Felt tired or having little energy?

On a scale of 0 to 3, how often over the past 2 weeks have you had : Poor appetite or overeating?

On a scale of 0 to 3, how often over the past 2 weeks have you : Felt bad about yourself — or that you are a failure or have let yourself or your family down?

On a scale of 0 to 3, how often over the past 2 weeks have you had : Trouble concentrating on things, such as reading the newspaper or watching television?

On a scale of 0 to 3, how often over the past 2 weeks have you been : Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual?

On a scale of 0 to 3, how often over the past 2 weeks have you been : Thoughts that you would be better off dead or of hurting yourself in some way?

Tick the checkbox if you have had plans to end your life in the last week

On a scale of 0 to 3, how often over the past 2 weeks have you : Felt nervous, anxious or on edge?

On a scale of 0 to 3, how often over the past 2 weeks have you : Not being able to stop or control worrying?

On a scale of 0 to 3, how often over the past 2 weeks have you : Worried too much about different things?

On a scale of 0 to 3, how often over the past 2 weeks have you had : Trouble relaxing?

On a scale of 0 to 3, how often over the past 2 weeks have you : Been so restless that it is hard to sit still?

On a scale of 0 to 3, how often over the past 2 weeks have you : Become easily annoyed or irritable?

On a scale of 0 to 3, how often over the past 2 weeks have you : Felt afraid as if something awful might happen?

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