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Systemic Psychotherapy
Systemic Psychotherapy
Family Therapy
Couples Therapy Ireland
Family Conflict
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Our Therapists
Paddy Connolly
Madeleine Connolly
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Systemic Psychotherapy Ireland Intake Form
Click on this text to edit it.
Please leave blank:
Agreement
Please sign the statement of confidentiality & consent
here
INTAKE FORM
Client Name:
Age:
Gender:
Date of Birth:
Mobile:
Email:
Home Address:
Is the client an adult?
Yes
No
If the client is an adult (18 years of age or older) please provide an emergency contact and General Practitioner (Doctor) details
Emergency Contact
Name:
Relationship to client:
Mobile phone number:
Email:
Doctor Details
Name:
Mobile Number:
Email:
If the client is a child (under 18 years of age) please fill in information on parents/guardians
Name of parents/guardians:
Relationship to Client:
Address if different to above:
Relationship Status:
Single
Married
Widow(er)
Cohabitating
Divorced
Re-Married
Other
Name of Spouse or Partner:
Emergency Contact:
Phone Number:
Email:
Relationship to Client:
Preferred Method of Contact for Appointment Reminders or Therapist Contact:
Phone
Text
Email
Please List Seperatly: Names of Children - DOB - Living in the Home Yes/No:
PLEASE COMPLETE THIS SECTION IF CLIENT IS UNDER 18
Father’s Name:
Date of Birth:
Father’s Address (If different than client):
Mother’s Name:
Date of Birth:
Mother’s Address (If different than client):
Parents Relationship:
Married
Divorced
Separated
Widow(er)
Never Married
Client’s Legal Guardian(s):
Provide contact information here if not listed elsewhere on form:
Address:
Phone number:
Date of Birth:
If parents are not together or married or child is currently in care/adopted etc, who has the right to make medical decisions?
You may be required to provide therapist with custody and other legal paperwork needed to ensure therapist has permission by guardians to see client.
Purpose of Therapy
Please select:
Couples Therapy
Individual Therapy
Family Therapy
Please check all that apply to you and may be a focus of treatment:
Please check all that apply:
Anxiety
Depression
Relationships and Boundary Issues
Lying/Manipulation
Academic Problems (Children and Adolescents)
Behavioral Problems (Children and Adolescents)
Marital Concerns
Dealing with Divorce
Parenting Concerns
Risk of harming yourself or others
Anger Issues
Developmental Problems
Sleep Problems
Confidence/Self-Esteem Issues
Feeling Isolated From Others
Afraid or Suspicious
Losing Track of Time
Please check all that apply:
Nightmares
Intrusive Memories
Sexual Issues
Stress Management
Traumatic Experiences
Sexual Abuse
Physical Abuse (Including Domestic Violence)
Emotional/Mental Abuse
Loss of Control
Destructive Life Patterns
Substance Abuse (Past and/or Present)
Family of Origin Issues
Career Changes
Financial Problems
Specific Fears or Panic
Memory Problems
Other
BRIEF SURVEY
(a child or young person may be supported by a parent/guardian to answer the following)
What brings you in to therapy today?
Where did you hear about SPI?
What are you hoping for in your therapy experience?
What are your concerns about therapy if any?
Have you ever been in therapy before, if so, when, and how long for?
If yes, was your experience positive or negative and why?
Anything you would like to add?
Send
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