Child & Adolescent Registration Form

Form

Name of Parent or Guardian of Young Person

Name, number and relationship to young person

Emergency Contact Email Address

Please enter the email address

First Name of Young Person

Surname of Young Person

Date of Birth of Young Person

Sex

Gender Identity

Preferred Pronouns (optional)

Address Line 1 (Required)

Address Line 2 (optional)

Address Line 3 (optional)

City (Required)

Postcode (Required)

Telephone (Required)

Email (Required)

GP Name (optional)

GP Address (optional)

{name}

GP Email (optional)

GP Website (optional)

GP Contact - Do you give us permission to contact your GP?

Please note that for a medical appointment with our Consultant Psychiatrist, we will require consent to contact your GP.

Is your GP aware of the concerns you have for your young person?

Do you intend to use a private health insurance policy?

How did you find us?

What days and / or times would you be able to make a regular treatment

{name}

Would you prefer to be seen in London, Hertford, Richmond or remotely

(please type your answer in the box below - note that a combination of in person and remote is fine)

{name}

New Client Questionnaire Please note the following questionnaire is OPTIONAL, and is requested only if you are comfortable to disclose information in this way. The questions are aimed at helping us to gain a better understanding of your current situation and will be used to inform decisions about which treatment approach or which clinician may be most appropriate to assess you.

Has your young person previously been diagnosed with a mental health condition?

Has your young person previously received treatment for a mental health condition?

Eg. inpatient, day patient, group therapy, family therapy, cognitive behavioural therapy, psychodynamic therapy, hypnotherapy, pharmacotherapy, or other…

Do you currently have any concerns in relation to your young person’s eating or exercise habits?

Eg. restrictive eating, overeating, binge eating, emotional eating, yo-yo dieting, vomiting after eating, food-related anxiety, poor diet/nutrition, overexercising, exercise avoidance, or other…

Do you currently have any concerns in relation to your young person’s weight/shape/appearance?

Eg. recent weight loss/gain, underweight, overweight, fear of gaining weight, body dissatisfaction, preoccupation with weight/shape/appearance, cosmetic surgery, weight loss surgery, or other…

Do you currently have any concerns in relation to your young person’s mood?

Eg. mood swings, depression, anxiety, mania, suicidality, deliberate self-harm, or other…

Are you or your young person currently experiencing any other difficulties in your life that are not related to the above questions?

Eg. relationship problems, family problems, work stress, bereavement, other mental health concerns, physical health problems, or other…

If you know your young person's current weight and height and are comfortable to let us know, please share the details below, however, this is not mandatory.

Current Weight (if known)

{name}

Current Height (if known)

{name}

Is there anything else which you would like your therapist to be aware of prior to seeing you and your young person for the first time?

Alert