The Intake Form Template UK is offered in multiple formats, including PDF, Word, and Google Docs, featuring editable and printable versions for your convenience.
Intake Form Template UK Editable – PrintableSample
Intake Form Template UK 1. Client Information 2. Emergency Contact Information 3. Medical History 4. Current Medications 5. Health Insurance Information 6. Reason for Visit 7. Consent for Treatment 8. Data Protection Agreement 9. Feedback and Communication Preferences 10. Signature and Declaration
PDF
WORD
Examples
[Client Name]
[Client’s Date of Birth]
[Client’s Address]
[Client’s Phone Number]
[Client’s Email]
[How did you hear about us?]
[Referring Person or Organization]
[Emergency Contact Name]
[Emergency Contact Phone]
[Relationship to Client]
[Please provide a brief description of your background and needs. Include relevant personal and health information.]
[What specific services or assistance are you seeking? Please provide details.]
[What are your short-term and long-term goals?]
I, [Client Name], consent to share my information for the purpose of providing services. [Signature Line or Box]
[Client Signature] [Date]
[Full Name]
[Date of Birth]
[Address]
[Contact Number]
[Email Address]
[Please describe your primary concern or reason for seeking assistance.]
[Have you received any similar services in the past? If so, please elaborate.]
[Who is part of your support network? Include family, friends, or healthcare professionals.]
[How long have you been experiencing this issue?]
[Phone, Email, In-person, Other (please specify)]
I understand that my information will be kept confidential and will only be used for the purposes of providing care. [Signature Line or Box]
[Client Signature] [Date]
Printable
