Individual Psychotherapy with

Liesel Greyling

Integrative Psychotherapist

This document outlines the professional, ethical, and legal frameworks that inform my psychotherapy practice and our therapeutic relationship. Please read the information, fill in the required information and provide the consent requested within.

Initial Psychotherapy Assessment & Intake Form

The purpose of this document is to help us explore your current needs, your background, and your goals for therapy. By gathering this information before we agree to a session, we can build a clear picture of what you are experiencing and ensure that online psychotherapy is the right and safe space for you, and that I have the necessary expertise to help you achieve your specific therapy goals.

What Happens to Your Completed Form

All information provided in this form is strictly confidential. Your data is handled and securely stored in full compliance with UK Data Protection law (UK GDPR) and my registration with the Information Commissioner's Office (ICO). It will not be shared with anyone without your explicit consent, except under the rare legal and safeguarding limits outlined in our Individual Client Therapy Agreement.

Should you choose not to start therapy with me, I will permanently and securely delete this form.

1. Client Administrative & Contact Details

Full Name *

Date of Birth

Age

Pronouns

Contact Number *

Can I leave a voicemail?

YesNo

Email Address *

Physical Address (Where you will be during online sessions) *

Postcode *

GP Practice Name & Address

GP Phone Number

Emergency Contact Details

Full Name *

Relationship *

Contact Number *

2. Is Online Therapy Safe and Practical for You?

Please check all that apply to your current environment:

I have access to a completely private, quiet room where I cannot be overheard.I have a stable internet connection and a reliable device with an operational camera.I understand and agree that no part of the online sessions will be recorded.

3. What Is Going on For You Right Now?

Please select from the below which of these represent the core challenges bringing you into therapy at this time. If multiple challenges apply, please number them to show which is impacting you the most right now (1 = main focus, 2 = secondary focus, etc.):

Please also indicate and specify if the following applies to you (e.g. ADHD, Autism, Bipolar, OCD, Borderline Personality/EUPD, etc.):

4. Are You Struggling Specifically with Anxiety, Depression, Addiction, or Suicidality?

Please check all the boxes below that apply to you, if you do:

Anxiety Symptoms

Frequent or uncontrollable worrying about multiple different thingsPhysical tension, muscle aches, or inability to relax the bodySudden episodes of panic, rapid heart rate, or shortness of breathRestlessness, feeling on edge, or difficulty concentrating due to worryAvoiding specific places, people, or situations due to fear or anxiety

Depression Symptoms

Persistent low mood, sadness, or feeling empty most daysLoss of interest or pleasure in activities you normally enjoySignificant changes in appetite or weight (increases or decreases)Chronic fatigue, low energy, or feeling physically slowed downFeelings of worthlessness, excessive guilt, or low self-belief

Addiction & Substance Use

Using alcohol, prescription medication, or recreational drugs to cope with stress/emotionsHaving persistent thoughts or urges to cut down on your consumption/behaviourExperiencing criticism, concern, or comments from others about your habitsFeeling guilt, regret, or shame regarding your substance use or behavioursYour habits are negatively impacting your work, relationships, or physical health

Suicidality, Self-Harm & Safeguarding

Please answer these items accurately to help us establish a safe framework:

Passive Ideation: I experience thoughts of wishing I were not here, sleeping and not waking up.Active Ideation: I experience active thoughts or intent regarding ending my life.Historic Risk: I have previously attempted suicide or engaged in high-risk self-harm in the past.Self-Harm: I am currently engaging in, or feel strong urges to engage in, physical self-harm.None: None of the above risk or self-harm factors apply to me at this time.

EMERGENCY & CRISIS DISCLAIMER:
This private online practice does not provide an immediate emergency or crisis intervention service. If you feel unsafe, are in immediate danger of hurting yourself, or are experiencing a severe mental health crisis, please contact your local emergency services immediately by calling 999 or visiting your nearest Accident & Emergency (A&E) department. You can also call the NHS medical line on 111, contact your local GP surgery, or call the Samaritans for free confidential support on 116 123.

5. Do You Take Subscribed Psychotropic Medication?

Please tick any medications you are currently prescribed to manage your mental health:

Antidepressants (SSRIs / SNRIs / Tricyclics)

Anti-Anxiety Medications & Sedatives (Benzodiazepines / Beta-Blockers)

Diazepam (Valium)Lorazepam (Ativan)Alprazolam (Xanax)Propranolol (Beta-blocker used for physical anxiety symptoms)Pregabalin or Gabapentin (Lyrica / Neurontin)Z-Drugs (e.g., Zopiclone or Zolpidem for sleep)

Mood Stabilisers & ADHD Medications

Antipsychotic Medications (Neuroleptics)

Quetiapine (Seroquel)Olanzapine (Zyprexa)Risperidone (Risperdal)Aripiprazole (Abilify)

Other Medications

Other medication not listed above (please specify generic or brand name):

Current Dosage & Frequency (if known):

6. Do You Have Any Prior Therapy Experience?

Have you engaged in professional therapy/counselling before?

YesNo

If YES, please briefly outline 1) The type of therapy (e.g. CBT), 2) when, 3) for how long, and 4) the primary focus of the therapy:

7. What Do You Want from Me as Your Therapist?

What style of therapy do you feel would suit you best? (Check all that apply):

Structured and tool-focused (exploring strategies, coping mechanisms)A reflective space to process, vent, and feel heardDeep exploration of past experiences, patterns, and childhoodI like a more interactive / engaged / directive approachI like to be challengedUnsure

8. Would You Like to Share Anything Else?

Please feel free to use this space here to elaborate or share anything else:

Thank You for Taking the Time to Complete this Initial Assessment!

Individual Psychotherapy Agreement & Informed Consent

1. What You Can Expect: Session Logistics & the Online Framework

a. Format & Platform:

All sessions are conducted online via a secure, GDPR-compliant Zoom platform. You will receive a unique access link prior to each scheduled appointment.

b. Session Duration:

The standard therapeutic hour is 60 minutes long.

c. Session Frequency:

For new clients, weekly sessions are advised for at least 6 consecutive weeks (where possible), to ensure that there is sufficient time between sessions for processing but not too big of a gap to interrupt the therapeutic process. If you are thinking of having less sessions than this, please use the contact us form before we get started to discuss this and see if it could foreseeably be viable.

d. Ensuring a Safe Therapeutic Environment:

It is important for both of us to access the session from a private, quiet space within the United Kingdom. To maintain confidentiality, you are requested not to attend sessions from public spaces. For your safety, you are also requested not to access therapy while driving.

e. Technical Disruptions:

In the unlikely event that our connection drops, we will first attempt to reconnect via the platform. Should the platform fail completely, I will call your mobile number to mutually decide if and how to complete the session or to reschedule.

2. Fees, Payments & Cancellation Policy

a. Session Fees:

The fee for individual psychotherapy is dependent on the session frequency and duration:

Duration	Frequency	Description / Indication	Fee
60 min Individual Session	Weekly	Recommended for: - New Clients - Complex Trauma Work	£60.00
	Bi-Monthly	Minimum requirement for: - New Clients - Complex Trauma Work - Clients tapering down weekly therapy	£65.00
	Sessional	Once a month or less for: - Clients talking through a very specific and confined challenge - Clients tapering down Bi-Monthly sessions - Clients seeking a 'maintenance' session following longer-term work	£70.00
+ 15 minutes	Ad Hoc	If a session requires additional time of up to 15 minutes either because: - The topic in session requires more time - The additional time is requested and pre-booked by the client	+£25.00

b. Payment Terms:

To secure your booking, payments should be made via bank transfer at the time of the booking or at least 48 hours before the scheduled session time. Sessions will not be considered confirmed until the payment is received, and without a payment reflecting 48 hours before the scheduled session, the slot may be given to another client.

c. Cancellation Policy:

B.Spoke Therapy Practice operates a strict 24-hour cancellation policy. If you cancel or request to reschedule an appointment with less than 24 hours' notice, or if you miss a session entirely, the full session fee remains payable.

3. Confidentiality & Legal Limits (UK Based Psychotherapy)

B.Spoke Therapy Practice is registered in the UK. As such, you will be accessing UK based Psychotherapy governed by UK law and the British Association for Counselling and Psychotherapy (BACP) framework. You can review the framework here: BACP Ethical Framework. Exceptional circumstances where confidentiality may be limited include:

a. Risk of Harm:

Duty of care regarding severe, imminent risk of serious harm to yourself or others.

b. Legal Mandates:

Court orders or UK legislation regarding terrorism, drug trafficking, or money laundering.

c. Safeguarding:

Ongoing abuse or neglect of a child or vulnerable adult.

d. Professional Supervision:

Anonymous case discussions with a Clinical Supervisor in line with BACP standards.

4. Data Protection & GDPR Compliance

a. Data Controller:

Registered with the Information Commissioner's Office (ICO).

b. Record Keeping:

Brief, anonymised notes stored securely for 3 years after therapy ends before being destroyed.

5. Communication & Crisis Support

a. Between Session Contact:

Administrative communications. Therapeutic support or crisis management is not provided over email/message.

b. Crisis Management:

In an acute mental health crisis, please contact your GP, NHS 111 (or 999 in emergencies), or Samaritans on 116 123.

6. Professional Standards, Ending Therapy & Consent

a. Ethical Adherence:

Registered member of the BACP.

b. Complaints:

Formal complaints can be filed directly with the BACP if concerns cannot be resolved together.

c. Planned Ending:

At least one week's notice is recommended before ending therapy for a closing session.

7. Legal Proceedings, Court Attendance, and Release of Records

a. Production of Notes:

Records are not disclosed without explicit written consent or a formal Court Order.

b. Witness Summons:

Restricted strictly to a "witness of fact" role regarding attendance dates and occurrences.

c. Legal Fees:

Professional time associated with legal requests or testimony is billed at £75 per hour.

8. Keeping You Safe During Sessions (Emergency Details)

In the event of a medical emergency or mental health crisis during a session, please provide the following information:

Your Details

Your Full Name *

Your Contact Number *

Your Physical Address (Where you will be during online sessions) *

Your GP Surgery

Surgery Name

Name of Doctor

Address

Contact Number

Your Emergency Contact

Person's Name *

Contact Number *

Relationship to You *

9. Client Consent & Signature

By signing below, I confirm that I am aware that I am accessing UK based Psychotherapy, and that I have read and understood the terms outlined in this Individual Psychotherapy Agreement & Informed Consent form. I further confirm that I voluntarily consent to engage in online therapy under these conditions.

Client Full Legal Name *

Date *

Electronic Signature / Full Legal Name *

Write Your Message

Name *

Email Address *

Contact Number *

Your Message

All completed forms are emailed directly to the therapist and not stored on a cloud or on the website. A copy is also emailed to you.

Thank You for Taking the Time to Complete this Initial Assessment!

Liesel will review your agreement and assessment and email you to arrange your first session.

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