Patient intake form

Client Intake Form Please complete before your first appointment Thank you for choosing us. This form helps us prepare for your first appointment and look after you well. What you write here is kept private. If a question does not apply, write “n/a”. You can skip anything you would rather talk about in person. Section 1: About you Full name ____ (Full name) Date of birth ____ (Date of birth) Phone ____ (Phone) Email ____ (Email) Address ____ (Address) Preferred contact ____ (How we should contact you) Section 2: Why you are here 2.1 What would you like help with? ____ (What would you like help with?) 2.2 What would you like to be different in six months? ____ (Your goals) 2.3 Have you had similar help before? ____ (Previous help). Anything else we should know before we start: ____ (Anything else) Section 3: Health and circumstances 3.1 Anything about your health, medicines or allergies that is relevant to the service (write “none” if nothing): ____ (Health information) 3.2 Do you have any needs, such as access, language or timing, that would help us serve you? ____ (Your needs) Section 4: Emergency contact 4.1 Name: ____ (Emergency contact’s name). Relationship: ____ (Their relationship to you). Phone: ____ (Their phone). Section 5: Background 5.1 Tell us briefly about anything in your history that you think is relevant, such as previous support, treatment or major life events. You do not need to share anything that you are not comfortable sharing yet. ____ (Background) 5.2 Current medicines or supplements: ____ (Medicines) 5.3 Who else is supporting you at the moment (family, friends, other providers)? ____ (People supporting you) Section 6: Appointments and practicalities 6.1 The days and times that suit you best: ____ (Days and times that suit you) 6.2 How did you hear about us? ____ (How you heard about us) 6.3 Is there anything that would make it easier for you to attend, such as an interpreter, step-free access or reminders? ____ (Things that would help you attend) Section 7: What happens at your first appointment 7.1 Your first appointment is a chance for us to get to know you and for you to get to know us. We will go through this form with you, explain how we work, answer your questions and agree together what you would like to achieve. There is no pressure to share more than you are ready to. 7.2 Please arrive a few minutes early. If you need to cancel or move your appointment, please tell us as early as you can, and at least the notice period we gave you when you booked. Section 8: How we use your information 8.1 We collect this information to provide the service, to contact you about your appointments, and to keep the records the law requires. We keep it securely and share it only with people who need it to provide the service, or where the law requires it. 8.2 You may ask to see what we hold about you, to correct it, and, where the law allows, to have it deleted. 8.3 ____ (You may contact me by phone and email about my appointments) You may contact me by phone and email about my appointments 8.4 ____ (I have read how my information is kept and used, and I agree to it) I have read how my information is kept and used, and I agree to it 8.5 ____ (What I have written is accurate and complete to the best of my knowledge) What I have written is accurate and complete to the best of my knowledge Signatures Thank you. Sign below to send us your form. Client ____ (Printed name) Printed name ____ (Client signature) Signature ____ (Client date signed) Date