Mental Health Treatment
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Questionnaire
 

Please provide us with as much information as you possibly can. 
All information is stored confidentially and will not be passed onto third parties without your consent.
General Information

Are you:            

The client Acting on behalf of the client
If on behalf of client, please state relationship:
Your Name:
Client’s Name (if applicable):

Age:
Gender:
Male Female

Town and Country of residence:

Please describe the problem in question:

Particular signs and symptoms:

Is there a family history of psychiatric illness:
Yes
No
Unsure

What is your available budget:
Limited Funds
£3,000 to £5,000
£5,000 - £10,000
£10,000 - £15,000
£15,000 - £20,000
In excess of £20,000

Do you have private medical insurance:

Yes If so, which provider:  
No

How did you hear about our service:
Internet search engine Please state:  
Yellow Pages
Word of mouth
Please provide us with any further information which you feel may assist us in efficiently handling your enquiry:
Contact Details

Telephone number:

Email Address:

Please reconfirm your email address:

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