Name *

First Name

Last Name

Parent/carer name (if referring a child)

First Name

Last Name

Suicidal thoughs/attempts? *

Yes

No

Self-harming behaviours? *

Yes

No

Eating-disordered behaviours *

Yes

No

Would you prefer a day/evening appointment?

Daytime

Evening

Don't mind

Have you ever been a client at Open Door? *

Yes

No

Has anyone related to you attended Open Door for counselling? *

Yes

No

Do you know anyone that works at Open Door? *

Yes

No