Flower Associates – Adult Questionnaire

Adult Questionnaire

Please fill in as much information as possible - thank you.

Name
First Last
Other Names
Nationality
Occupation
Employer
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Home Telephone Number
Email
Date of Birth
Date Format: DD slash MM slash YYYY
Sex
Hand Dominance
Adopted
At what age?
GP's Name
GP's Address
Street Address City State / Province / Region ZIP / Postal Code Country
GP's Telephone Number
Do you have a long term spouse/partner?
Your partner's name
Your partner's occupation
Number of dependents
Mother's Name
Mother's Occupation
Father's Name
Father's Occupation
Languages Spoken at Home
Other Siblings in the Family (Name, Sex, Date of Birth, Age)
Last Educational Placement
Have you had any major accidents resulting in a period of unconsciousness?
If yes, please specify
Have you been affected by any periods of major family stress?
Please specify:
What are your current concerns?
Have you had any treatment/help from other specialist professionals?
Please specify (e.g. visits to therapist, counsellors etc.)
Do you have any previous reports, especially from other psychologists?
Please specify including dates and by whom you were originally referred.
Are reports available?
Do you have any other comments that you feel might be useful?
I/ we agree that our personal data will be kept on file in accordance with the GDPR (General Data Protection Regulation.) I will contact Flower Associates if I wish to have my data rectified or removed. A link to the full description of the GDPR guidelines can be found on the previous page.
- Please check this box to accept you are happy to agree to these terms.