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MindTherapy

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- Depression
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FAQ
Contact
Media

Home
About
My Services
- Depression
- Anxiety
- Panic Attacks
- OCD
- Phobias
- PTSD
- Addictions
- Relationships
- Anger Problems
Emotional Needs
Forms
Book a Session
FAQ
Contact
Media

087-6575787
01-2042742
email: martin@mindtherapy.ie
Book Online Session

Before your session

To save time and get the most from your session it can be helpful to complete the online form below.

Instructions

Please read this HGI Information for Clients – GDPR document first.
For online sessions please read this Online Therapy Guidelines.
Please complete and submit the online Client Record Form & Confidentiality Agreement below.

Client Record Form

Today's Date

Name of Client

Date of Birth

Address

Mobile

GP Name

Address

If you are coming for Couples Counselling

Reason for last GP visit

Current prescribed medication or other remedies?

Are you receiving any other form of therapy?

How is your current physical health?

What do you want to change today?

Do you eat regular meals?

How many glasses of water do you drink daily?

Do you smoke?

Yes No

How many per day?

How much exercise do you get a week?

How many units of alcohol do you drink per week?

How many hours sleep per night on average?

How do you relax?

What are your hobbies/interests?

Are you presently employed?

YES NO

Job description

How well do you cope with stress?

Not very well Fairly Well Very Well

How did you find out about our services?

Psychology Today Human Givens Therapist Register Facebook MindTherapy Website Other

I am prepared for this information to be recorded and kept by my HG Therapist together with details of treatment sessions.

YES NO

Supervision Info

Type Name

Guardian digital signature required for clients age 16 and below

Confidentiality Agreement

I understand that all clinical information shared with my therapist will remain confidential within their service except where they believe there may be a risk of harm to myself or others, or where there’s a legal duty of disclosure.

YES NO

I have read and understood the HGI Information for Clients sheet.

YES NO

Type Name

Guardian digital signature required for clients age 16 and below

087-6575787
01-2042742
email: martin@mindtherapy.ie
Book Online Session