Support Form for Applicants to Mind in Mid Herts Services

Sonia Clarke Dip Couns. MBACP

Client Information Form Please complete and return. The information will be kept confidential

Name Surname: Title:

Address Post code

Contact No

Next of Kin

Date of Birth N of K No

Email address Yes No Are you currently under a Community Mental Health Team (CMHT) If yes Which team Contact name Are you currently working to a care plan set out for you by your CMHT

GPs name Surgery

Physical Health Check – (Optional. Do not need to complete) Yes No Has your doctor ever informed you that you have a heart condition? Do you have chest pains, which are brought on physical activity? Do you currently exercise regularly? Do you ever tend to faint or fall over as a result of dizziness? Do you have a bone or joint problem that is aggravated by any physical activity? Are you currently advised on limitations on any physical activity for any reason? Are you currently, or have been, pregnant in the last 6 months? Note: Are you taking any prescribed medicines? Note Do you have any health condition I should know about?

What gender are you? Male Female Other

Do you consider yourself to have a disability? No Yes Note:

Which ethnic origin are you? White - British White – European White - Other Irish Traveller Black or Black Black or Black Other Black Mixed – White & British - Caribbean British – African background Asian Asian or Asian Asian or Asian Chinese Mixed – White & British - Pakistani British- Black Caribbean Bangladeshi Mixed – White and Other Black African Please state:

What is your sexual orientation? Heterosexual Bisexual Homosexual Don’t wish to fill out (Opposite Sex) (Both Sexes) (Same Sex) Sonia Clarke Dip Couns. MBACP

In what way do you feel that counselling can help you?

Please give a brief outline of your history and the way that it can affect your life

What are the signs and symptoms when you become unwell?

Is there anything I should know about your past experiences which may help me in offering appropriate support?

Signature I have read this form and understood it. The details I have given are accurate and Signature: I give my permission to obtain risk assessments, CPA and/or referral Date: from CMHT or GP