PLEASE COMPLETE ALL PARTS OF THIS FORM IN FULL.
DUE TO FUNDING RESTRICTIONS, THE CLINICAL TEAM WILL DECIDE IF YOU ARE ELIGIBLE FOR THERAPY
PART ONE: PERSONAL DETAILSName: / Telephone number(s):
Address:
Postcode: / Email address:
Borough: / Date of birth:
Availability for appointments:
Our opening hours are Monday to Thursday 9-5pm. (The latest session will be 4pm)
Morning: q Afternoon: q
Preferred method of contact:Email: q Letter: q Phone: q
How did you hear about the Women’s Therapy Centre?Clinician q College/University q
Self q Counselling Organisation q
Voluntary/Community Sector q GP q
Media/Books q CMHT q
Social Services q WTC Website q
Other source {please specify} q Hospital q
Yes q No q If no, please say who helped you contact the Centre:
Why are you seeking therapy?Why did you choose the Women’s Therapy Centre?
Location of Centre q Low cost service q
Reputation q Women only service q
Other reason {please specify}
Are you currently receiving any psychological treatment at the moment?Yes q No q If yes, please state where:
GP name:GP address:
GP Tel. number:
PART TWO: EMPLOYMENT & INCOME
What is your current work situation?
In paid work: Full time q Part time q Self-employed q
Not in paid work q In receipt of state pension q Student q
If you are not in paid work, are you in receipt of any of the following benefits? Please write amount(s) £Incapacity Benefit £______Disability Living Allowance £______
Jobseekers Allowance £______Income Support £______
Working Tax Credits £______Housing Benefit £______
Child Benefit £______Carers Allowance £______
Attendance Allowance £______Employment & Support Allowance £______
NASS Accommodation £______NASS financial support £______
Student Loan £______In receipt of other benefits {please specify} £______
Not in receipt of benefits r Freedom Pass Yes r No r
If you have a current job, what is your occupation?What is your household annual income {including any benefits}?
Under £10,000 q £10,000 - £15,000 q
£15,000 - £20,000 q £20,000 - £30,000 q
£30,000 - £40,000 q Over £40,000 q
PART THREE: CHILDRENDo you have any children?
Yes q No q
If yes, please state how many children you have in each age group:Aged 0 – 4 ___ Aged 5 – 12 ___ Aged 13 – 17 ___
If you have any children under the age of 18, do they live with you?Yes q No – they live elsewhere in the UK q
No – they live outside the UK q No – I don’t know where they are q
Other {please specify}
If they live with you, do you care for them alone?Yes q No q
How many children aged 18 or over do you have?PART FOUR: MONITORING INFORMATION – ETHNICITY:
White:
British q Irish q Greek Cypriot q
Turkish q Kurdish q Albanian q
Kosovan q
Other white background {please specify}
Mixed:White & Black African q White & Black Caribbeanq White & Asian q
Other mixed background {please specify}
Asian or Asian British:Indian q Pakistani q Bangladeshi q
Other Asian background {please specify}
Black or Black British:African q Caribbean q
Other Black background {please specify}
Other Ethnic Group:Afghani q Arabic q Chinese q
Iraqi q Latin American q Middle Eastern q
Other Ethnic background {please specify}
Do you need an interpreter? Yes/No If yes, what language? ______
Are you a refugee or asylum seeker?Yes q No q
Gender Identity:Female q Transgender q Prefer not to say q
Other gender identity {please specify}
Sexual identity:Bisexual q Heterosexual q Lesbian q
Prefer not to say q Unsure q
Other sexual identity {please specify}
Religion/Belief:Agnostic q Atheist q Baha’i q
Buddhist q Christian q Hindu q
Humanist q Jain q Jewish q
Muslim q Rastafarian q Sikh q
Zorostrian q None q Prefer not to say q
Other religion/belief {please specify}
DISABILITYDo you consider yourself to have a disability? Yes q No q
Long-term condition – Diabetes, lupus, asthma, rheumatism, arthritis, cancer, MS etc q
Blind or visual impairment q Deaf or hearing impairment q
Learning Difficulty q Mental Health q
Mobility q Prefer not to say q
Other disability {please specify}
Page 3 of 3