include international dialing code if outside of UK
including postcode
Full Name
For our awareness, please give details of your current psychological medication use- including names and dosages. Enter N/A if there is no current medication.
Please tick those which apply to you and if there is any risk please give further details below.

If it's an emergency or you're in need of immediate help then your first point of call is to contact your Local GP or Emergency Services, or alternatively call NHS Direct on 111 or Samaritans on 116 123.
Please detail all relevant details of any third party that is involved or paying on your behalf. For example; employer, insurance provider etc.
Please tick all that apply and add relevant details in the box below.
Please add any relevant details of the above ticked conditions, and any further details of any other medical issues not mentioned that you feel is relevant.
Please give further details of any of the above ticked items including amount, frequency and any other details you feel relevant.
If so, please give details of what, how much and how regularly?