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New Patient Intake
Hosted at practeese.com/forms/new-patient-intake
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Full name Required
Short text
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Date of birth Required
Date
DD / MM / YYYY
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What brings you to therapy? Required
Long text
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Had therapy before?
Yes / No
YesNo
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Current mood (1–10)
Scale
${[1,2,3,4,5,6,7,8,9,10].map(n=>`${n}`).join('')}
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Primary concern
Multiple choice
AnxietyDepressionTraumaOther
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Emergency contact Required
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Name and phone number…
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James Harlow — New Patient Intake
CompletedSubmitted 4 Mar 2026
Full name
James Harlow
Date of birth
12 / 06 / 1988
What brings you to therapy?
I've been struggling with anxiety at work for about two years. It's affecting my sleep and concentration. I've tried managing it on my own but I think I need proper support.
Had therapy before?
Yes
Mood rating
4 / 10
Primary concern
Anxiety
Emergency contact
Claire Harlow (wife) · 07712 345 678
Consent
✓ Agreed to privacy policy