Client Intake Form – Fergus Evans Therapy

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Name

Date of Birth

Email

Phone Number

Address

Identities

Pronouns

Access Needs

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Email

GP Practice Name

GP Practice Email

GP Practice Address

Fees (please choose the fee that best fits your financial circumstances)

£75 Full Cost INDIVIDUAL £60 Reduced Cost INDIVIDUAL £30 Low Cost INDIVIDUAL £75 Full Cost RELATIONSHIP £60 Reduced Cost RELATIONSHIP £30 Low Cost RELATIONSHIP £50 Full Cost GROUP £40 Reduced Cost GROUP £20 Low Cost GROUP

Are you hoping to work together primarily online or in person? (Please note that if you choose 'online' you are welcome to work together in person from time to time, and vice versa)

Online In Person

Where did you hear about me?

Google Counselling Directory BACP Website Psychology Today Recommendation from a friend Recommendation from another therapist

If you chose 'recommendation from a friend or another therapist, please specify who.

No Availability

I am afraid that I do not have any availability at the moment and am not taking on any new clients. If you are looking for a therapist who is queer, trans, and / or polyamory affirming you may wish to visit the Pink Therapy directory.

Visit Pink Therapy