Adult Registration Form

Form

First Name

Last Name

Date of Birth

Sex

Gender Identity

Preferred Pronouns

Address Line 1

Address Line 2

Address Line 3

City

Postcode

Telephone

Email

Emergency Contact

Name, number and relationship to patient

Emergency Contact Email Address

Please enter the email address

GP Name

GP Address

{name}

GP Email

GP Website

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.

Do you intend to use a private health insurance policy?

Invoicing information

For invoicing purposes, please provide the name, email address and mobile number for the person responsible for payment (N.B. Please note once an appointment is confirmed we do require 24 hours notice for any cancellations otherwise the appointment will be charged in full)

How did you find us?

Have you ever had contact with The London Centre previously? (for treatment and/or been on our waiting list previously?)

If you have a preference for days and/or times you are able to be seen, please let us know

{name}

Would you prefer to be seen in London, Manchester, 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.

Do you have any preferences regarding the type of treatment you would like or are there any particular treatment approaches or therapeutic styles that you think might benefit you?

{name}

Have you previously been diagnosed with a mental health condition?

Have you previously received treatment for a mental health condition?

Do you currently have any concerns in relation to your eating or exercise habits?

Do you currently have any concerns in relation to your weight/shape/appearance?

Do you currently have any concerns in relation to your mood?

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

If you know your 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 for the first time?

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