Booking - The St Andrews Practice

Please complete the form below. Once we have reviewed the information provided, we will contact you to arrange an initial assessment appointment with you.

All information submitted is treated as highly confidential and is compliant with GDPR data protection laws.

Name

Telephone

Postal Address

Date of Birth

GP & Practice Address

Please Select Your Service

Please Type Service Required if not in the list

Reason for seeking support - please briefly outline the main difficulties/symptoms you are experiencing - this could be with thoughts, emotions, memories, behaviours

How long have you been experiencing these types of difficulties?

Have you have had any treatment before now? If so please describe what this was

Do you have any diagnosed mental health difficulties? If so, tell us who gave you this diagnosis

Have you seen your GP about your difficulties?

Please let us know if you are currently taking any medications, if you have any physical health problems and if you have any allergies.

IMPORTANT: additional information required! Please describe any hospitalisations, history of deliberate self-harm, suicide attempts, addictions, psychotic episodes, any previous or current input from psychiatry or community mental health services and previous prescriptions for psychiatric medications. Please not that if you do not disclose these incidences it may result in your treatment being disrupted or terminated.

Emergency Contact Name

Emergency Contact Phone Number

I would like to use an insurance policy to cover the cost of my appointments

Yes No

Name of insurance provider:

Terms and conditions

I have read the terms and conditions & agree to the privacy policy