Mr / Ms / Mrs / Dr / Mx etc.
e.g. 25/12/1980
e.g. Heterosexual / Gay or Lesbian / Bisexual / Pansexual etc
Please include your postcode
e.g. Next of Kin / Partner
if applicable
if applicable please provide the name and dose of the medication
This might include longer term difficulties or historical difficulties which are different to the main reason you are seeking therapy currently. E.g. difficulties with food / drugs or alcohol / self harm / relationship difficulties etc.