Client form page | New Life Therapy

Client Information Form

In filling out this form digitally, you are agreeing that your electronic signature (typing your name) is the legally binding equivalent of your handwritten signature.

Name

Email Address

Phone Number

Date

Your Address

Your Town

Your County

GP Name

GP Address

GP Town

GP County

Reason for last GP visit

Current prescribed medication or remedies?

Do you eat regular meals?

How is your current physical health?

How much water do you drink?

Do you smoke?

How much exercise do you get each week?

Do you drink alcohol?

Are you happy with the amount that you drink?

Do you sleep well?

How many hours?

How do you relax?

What are your hobbies / interests?

What would you like to change today?

Do you enjoy your work?

How well do you cope with stress?

How did you hear about our services?

We would like to email you occasionally with our blog or information that we think will be helpful. If you’d rather not be added to our mailing list, please tick. We would like to email you occasionally with our blog or information that we think will be helpful. If you’d rather not be added to our mailing list, please tick. Remove me from the mailing list

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

Confidentiality Agreement

In filling out this form digitally, you are agreeing that your electronic signature (typing your name) is the legally binding equivalent of your handwritten signature.

Name

Email Address

Phone Number

Date

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. 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. I understand

My therapist has case supervision with their supervisor where a broad outline of my case may be discussed as a part of the supervisory process and that no identifying details will be revealed. My therapist has case supervision with their supervisor where a broad outline of my case may be discussed as a part of the supervisory process and that no identifying details will be revealed. I understand

I have read and understood the HGI Information for Clients sheet, including the section about use of questionnaires and how the data will be used in service evaluation and research, and I understand that by ticking the box below I am giving permission for my anonymised data to be used for service evaluation and research and that I can withdraw my consent to this at any time by contacting my therapist. I have read and understood the HGI Information for Clients sheet, including the section about use of questionnaires and how the data will be used in service evaluation and research, and I understand that by ticking the box below I am giving permission for my anonymised data to be used for service evaluation and research and that I can withdraw my consent to this at any time by contacting my therapist. Yes

My personal information will be kept in accordance with the Data Protection legislation. By ticking the box opposite, I consent to information about me being held by the therapist, which means that they will: My personal information will be kept in accordance with the Data Protection legislation. By ticking the box opposite, I consent to information about me being held by the therapist, which means that they will: Use my contact details only to get in touch with me about matters relating to my treatment, such as appointments and to provide helpful information, where appropriate. Not share my personal information with other individuals or organisations, except where they have reason to believe that I or others to be at risk of harm, or where there is a legal duty to disclose it Retain a record of my treatment for a period of 7 years, in accordance with professional requirements and will take steps to ensure the accuracy and security of the record. Provide me with access to the information they hold about me, if I request it.

The Emotional Needs Audit

How well are your needs being met?

Nature has programmed all of us with physical and emotional needs. These are the ‘human givens’ that cannot be avoided. How stressed we are depends on how well they are being met now, and how well we deal with the situation when they are not. Rate, in your judgement, how well the following emotional needs are being met in your life now, on a scale of one to seven (where 1 means not met at all, and 7 means being very well met), by ticking the appropriate boxes.

Name

Date

Do you feel secure in all major areas of your life? (Such as your home, work, environment)

Do you feel you receive enough attention?

Do you feel you give other people enough attention?

Do you feel in control of your life most of the time?

Do you feel part of the wider community?

Can you obtain privacy when you need to?

Do you have at least one person in your life that totally accepts you for who you are, emotionally and physically?

Do you feel an emotional connection to others?

Do you feel you have status that is acknowledged by colleagues, friends or family?

Are you achieving things and competent in at least one area of your life?

Are you mentally and/or physically stretched in ways which give you a sense of meaning and purpose?

If your scores are mostly low, you are more likely to be suffering stress symptoms. If any need is scored 3 or less, this is likely to be a major stressor for you. Even if only one need is marked very low, it can be enough of a problem to seriously affect your mental and emotional stability. Stress, anxiety, anger, depression and addiction are the result of our innate needs not being met, either due to environmental factors, harmful conditioning or a misuse of the imagination (worrying). People do not have mental health problems when their innate needs are being met in balanced, healthy ways. By highlighting ares in your life where your essential needs aren’t being met as well as they could be, you can use this questionnaire to help you think constructively about how your life could be improved.

CORE-10 Screening Measure

Clinical Outcomes in Routine Evaluation

Over the last week…

Name

Date

Gender

I have felt tense, anxious or nervous

I have felt I have someone to turn to for support when needed

I have felt able to cope when things go wrong

Talking to people has felt too much for me

I have felt panic or terror

I have made plans to end my life

I have had difficulty getting to sleep or staying asleep

I have felt despairing or hopeless

I have felt unhappy

Unwanted images or memories have been distressing me

In-Person & Online Therapy Available

Client Information Form

In filling out this form digitally, you are agreeing that your electronic signature (typing your name) is the legally binding equivalent of your handwritten signature.

Confidentiality Agreement

In filling out this form digitally, you are agreeing that your electronic signature (typing your name) is the legally binding equivalent of your handwritten signature.

The Emotional Needs Audit

How well are your needs being met?

CORE-10 Screening Measure

Clinical Outcomes in Routine Evaluation