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The Knightsbridge Practice

Therapy, Redefined.

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Intake From

Personal Details

First name*

Last name*

Date of Birth*

Day

Month

Year

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Phone*

Email*

Emergency Contact

Full Name*

Relationship to you*

Phone Number*

GP Details

GP Name*

Practice Name & Address*

Phone Number*

Medical & Mental Health Background

Do you have any current or historical mental health diagnoses?*

Yes

No

If yes, please provide brief details:

Are you currently taking any medication related to your mental health or wellbeing?*

Yes

No

If yes, please specify:

Have you previously received psychological therapy or counselling?*

Yes

No

If yes, please indicate when and the nature of the support received:

Reason for Seeking Therapy

Please share a brief summary of what has brought you to therapy at this time: *

Referral Information

How did you hear about The Knightsbridge Practice?*

GP or Psychiatrist

Insurance Provider

Online

Word of Mouth

Other

If other, please specify

Are you using private medical insurance?*

Yes

No

If yes, please provide: Insurance provider

Policy number

Authorization code

Intake Questionnaire: Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things*

Feeling down, depressed, or hopeless*

Trouble falling or staying asleep, or sleeping too much*

Feeling tired or having little energy *

Poor appetite or overeating*

Feeling bad about yourself — or that you are a failure or have let yourself or your family down*

Trouble concentrating on things, such as reading the newspaper or watching television*

Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual*

Thoughts that you would be better off dead or of hurting yourself in some way*

Feeling nervous, anxious or on edge *

Not being able to stop or control worrying*

Worrying too much about different things *

Trouble relaxing*

Being so restless that it is hard to sit still*

Becoming easily annoyed or irritable *

Feeling afraid as if something awful might happen*

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