Initial Consultation

DiMascio Therapies Initial Consultation Form

Name

This field is for validation purposes and should be left unchanged.

Personal Details

Name

First Last

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone

Date of Birth

GP Name and Address

GP Name

Surgery Address

Next of Kin Details

Next of Kin Name

Next of Kin Phone

If any of these are, or ever have been an issue for you, please tick:

choices

Other and Details

Any other problem not listed above? Any details you would like to share about the boxes checked?

Please answer the following health questions ?

Are you taking anti-depressants?

Yes

If ‘yes’ which anti-depressant medication and for what symptoms?

Are you taking tranquillisers?

Yes

If ‘yes’ which tranquilliser medication and for what symptoms?

Are you taking sleeping pills?

Yes

If ‘yes’ which sleeping medication and for what symptoms?

Are you prescribed any other psychoactive medication?

Yes

If ‘yes’ which psychoactive medication and for what symptoms?

Have you ever received any other form of psychiatric or psychological treatment?

Yes

If ‘yes’ what treatment and for what symptoms?

Have you ever attempted suicide?

Yes

Do you suﬀer from or have you ever suﬀered from epilepsy?

Yes

Do you suﬀer from asthma?

Yes

Do you suﬀer from diabetes?

Yes

Are you or anyone in your family neurodivergent?

Yes

If ‘yes’, please detail who, what neurotype they present with, and whether they have received a formal diagnosis:

Please describe your family history situation brieﬂy and your experience growing up:

What were the key events for you during your childhood/teens and formative years?

Please list any other signiﬁcant events that you feel are relevant to our work together:

Client Contract

FEE: Standard rates are £90 per session unless otherwise agreed between us, and is to be paid prior to or within 24 hours of an appointment.

CANCELLATION: Please give as much notice as possible if you need to cancel an appointment. The full fee will be charged if less than 24 hours notice is given or for a non-arrival, with the exception of a medical emergency.

LATE POLICY: If you are late for your session, but arrive within the first 15 minutes, your remaining scheduled time will be honoured. If you are more than 15 minutes late, this will be considered a non-arrival and will lose the session in line with the above cancellation policy.

CONFIDENTIALITY: All communication taking place during therapy sessions is confidential, subject to certain provisions. I am not at liberty to withhold information from the courts. I may be required to breach confidentiality if there is a possibility that you or another person is at risk of serious harm. It is considered confidential if an NHS professional requires information to be able to help you. Parts of your conversation may be referred to during clinical supervision, a requirement for registered therapists, although your name or any identifying details would not be disclosed.

PERSONAL DATA: Please refer to my Privacy Policy to find out how I collect, process, and store your personal data in accordance with data protection law. You can access this at http://dimasciotherapies.co.uk/privacy/

GUARANTEES: There are a number of complex factors inﬂuencing the success of individual session work and, whilst beneﬁts are typically observed in the majority of cases, results vary between individual clients and we do not guarantee success. We cannot provide medical advice or medical diagnosis. You are responsible for contacting your GP or other medical professional for medical advice and before making any changes to your medical treatment.

DRUGS & ALCOHOL: Please do not attend sessions under the inﬂuence of recreational drugs or alcohol as these can numb or alter emotions and reduce the eﬀectiveness of therapy.

CONTACT BETWEEN SESSIONS: To maintain appropriate therapeutic boundaries contact between sessions will be limited to arrangements for session dates and times unless otherwise agreed between us.

These are the terms that we both agree to abide by. Please keep a copy of this document for your own reference.

Please check the box below to consent to therapeutic treatment in accordance with these terms and to acknowledge that you have been given a copy of my Privacy Policy. In doing so you also consent to being on my mailing list, from which you can unsubscribe at anytime.