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Justine Wilson cognitive behavioural psychotherapist in Naas County Kildare

Tel: 086 109 7247 | Email: info@justinewilsonpsychotherapist.ie

Providing evidence based cognitive behavioural psychotherapy to adults & workplace counselling in Naas/Newbridge, Co. Kildare and Online

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Health/Medical History

Please complete this form before your consultation session

First name only and 1st letter of Surname *

For confidentiality please write only your first name and first letter of your surname

E.G. Justine W

Pease detail any health/medical conditions

This information is required to accommodate inclusivity to attend sessions for maximum benefit e.g. dyselxia, hard of hearing etc.

To understand if any health conditions impact you psychologically and emotionally

Are you taking any psychiatric medication/s that impact your mood and emotional regulation/stabalisation?

Yes

If Yes please give details of medication

Have you attended a mental health service previously (counselling, psychotherapy, psychiatric services)*

Yes

This information is collected to gain a history of mental health services.

If YES please give details

Have you been diagnosed or suspect a diagnosis of the following conditions?

Alcohol/Substance abuse

Anxiety (GAD)

Bi-Polar Disorder

Borderline Personality Disorder

Chronic Illness/Chronic Pain

Depression

Eating Disorder

Emotional Dysregulation Disorde

Neurodivergent (ADHD, Autism)

Obsessive Compulsive Disorder (OCD)

Personality Disorder

Phobia

Post Traumatic Stress Disorder (PTSD)

Schizophrenia

Social Anxiety (SA)

Stress

Have you been hospitalised in a psychiatric unit/settig in the past?*

Yes

If YES please give details

Is there a history of any mental health illnesses, substance abuse or violence within your immediately family (i.e. mother, father, grandmother, grandfather, sister, brother, uncle or aunt) - please provide details

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CONTACT: Justine Wilson Cognitive Behavioural Psychotherapist in Naas/Newbridge

Unit W9E&F, Block W9, Ladytown Business Park, Naas, Co. Kildare, W91 NN84

Tel: 086 109 7247 | Email: info@justinewilsonpsychotherapist.ie

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