Client confidential information

Please highlight this form and then copy & paste it into an email. Then fill it out and send it to me at kevanowen@hgtherapy.eu. Please answer every question as this information will help me greatly to structure the session.

If you are using a shared computer, please remember to delete it from the “sent items” folder and temporary files folder once you have sent it and I have acknowledged receipt.

Name:

Male/Female:

Date of Birth:

Married/Single/Divorced/In a relationship/etc:

Address:

Telephone Number(s):

Is it OK for me to leave messages?  Yes/No

Email:

GP’s name and practice address:

What is the specific problem in your life that is leading you to seek help?

How has this affected your life?

When did this issue first begin?

When was it/ is it different?

Are you receiving any other form of therapy?

Current prescribed medication or other remedies?

Approximate alcohol intake per week?

Do you smoke?

Any other drug use?

Do you sleep well?

How do you relax?

How is your current physical health?

What are your hobbies/interests?

If employed, what kind of work do you do?

If employed, do you enjoy your work?

How well do you cope with stress?

How did you first find out about this service?

What are your expectations of the session and how it will be structured?

What stops you from changing?

What will be different once you have changed?

How will this change affect family and friends?

What has been your best accomplishment to date?

Statement of Understanding:

The therapeutic approach used is the Human Givens Approach which incorporates solution-oriented brief therapy and counselling.

The date, location and frequency of sessions are negotiated between yourself and your therapist. Sessions are typically up to 90 minutes in length.

The fee will be between £45 and £60 depending on the length of the session, payable at the end of each session. It is also possible to pre-pay by using internet credit card payments by PayPal.

If you are unable to attend at the pre-arranged time, please advise your therapist as soon as possible and if at all possible at least 24 hours prior to your appointment. The session will be re-scheduled.

Everything discussed in the therapy and all information supplied remains confidential except in situations where there is a serious threat to life/safety of an individual or where there is disclosure of abuse/neglect of a child or vulnerable adult. If it were considered necessary to break confidentiality, your therapist will make every effort to encourage and support your involvement in this process.

Case records are retained by your therapist in secure storage and all information within them will not be released without your written permission.

Do you understand and agree to the terms listed above?

Today’s date: