One off Therapy / Psychological Report & Direction Session - Booking Form

Pre-Session Information Form

Thank you for your interest in the Psychological Assessment & Direction Session. This form helps me understand your background and what you're hoping to gain, so our time together is focused, meaningful, and useful for you. There are no right or wrong answers. Please answer as honestly as you can.

Section 1: Basic Information

Full Name

Date of Birth

Preferred Contact Email

Preferred Contact Number

Preferred Pronouns (optional)

Your Address (optional)

GP Name (optional)

GP Address (optional)

What made you consider this assessment now?

Which of the following feel relevant to you? (Tick all that apply)

Are you currently working?

Are there particular times of day, situations, or environments where things feel harder?

Which of the following do you experience regularly? (Tick all that apply)

Feeling constantly "on edge" or alert

Emotional overwhelm

Difficulty switching off

Feeling numb or shut down

Sudden irritability or impulsive reactions

Mental fatigue or exhaustion

Difficulty concentrating or focusing

Strong emotional reactions that feel hard to control

None of the above / unsure

How would you describe your stress levels day-to-day?

Low

Moderate

High

Fluctuates significantly

Have you had therapy or psychological support before?

Yes

Have you ever been diagnosed with any of the following? (Tick all that apply)

Do you suspect you may be neurodivergent, even without a diagnosis?

Yes

Unsure

What would feel most helpful to understand by the end of the session?

Which of the following are you hoping this assessment will help with? (Tick all that apply)

Deciding whether therapy is right for me

Understanding what kind of therapy or therapist would suit me

Understanding my brain and nervous system

Exploring ADHD / autism / neurodiversity

Making changes without needing therapy right now

Understanding work difficulties or adjustments

Gaining clarity and direction

Other

Are you happy to take part in a short introductory neurofeedback / EEG observation session as part of the assessment?

Yes

I'd like more information first

Is there anything you feel I should be aware of before we meet?

Please confirm:

I understand this assessment is not a formal diagnostic service

I understand this session provides psychological insight and direction

I understand the report reflects professional opinion based on the information available

Signature

Signature (type name)

Date

One Off Therapy / Psychological Assessment & Direction Session

One off Therapy / Psychological Report & Direction Session - Booking Form

Section 1: Basic Information

Which of the following feel relevant to you? (Tick all that apply)

Are you currently working?

Are there particular times of day, situations, or environments where things feel harder?

Which of the following do you experience regularly? (Tick all that apply)

How would you describe your stress levels day-to-day?

Have you had therapy or psychological support before?

Have you ever been diagnosed with any of the following? (Tick all that apply)

Do you suspect you may be neurodivergent, even without a diagnosis?

What would feel most helpful to understand by the end of the session?

Which of the following are you hoping this assessment will help with? (Tick all that apply)

Are you happy to take part in a short introductory neurofeedback / EEG observation session as part of the assessment?

Is there anything you feel I should be aware of before we meet?

Please confirm:

Signature

One Off Therapy / Psychological Assessment & Direction Session

One off Therapy / Psychological Report & Direction Session - Booking Form

Section 1: Basic Information

Which of the following feel relevant to you? (Tick all that apply)

Are you currently working?

Are there particular times of day, situations, or environments where things feel harder?

Which of the following do you experience regularly? (Tick all that apply)

How would you describe your stress levels day-to-day?

Have you had therapy or psychological support before?

Have you ever been diagnosed with any of the following? (Tick all that apply)

Do you suspect you may be neurodivergent, even without a diagnosis?

What would feel most helpful to understand by the end of the session?

Which of the following are you hoping this assessment will help with? (Tick all that apply)

Are you happy to take part in a short introductory neurofeedback / EEG observation session as part of the assessment?

Is there anything you feel I should be aware of before we meet?

Please confirm:

Signature