Patient Identification & Consent Form

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Dr Mathew McCauley, Consultant Clinical Psychologist
Suite 13, Blackrock Clinic, Rock Road, Blackrock, County Dublin, Ireland
Tel: 01-2064217; Fax: 01-2780354
PATIENT IDENTIFICATION & CONSENT FORM
Date:
Name:
Address:
Date of Birth:
Age:
Telephone/Mobile:
GP:
Address:
Telephone:
Next of Kin:
Address:
Telephone/Mobile:
Other current professionals involved in your care
Address:
(i.e. psychiatrist, social worker, etc)
Professional’s Name:
Profession:
Telephone:
Use this space if listing details of more than one other
Address:
professional:
Telephone:
Advance Directives: Have you legally documented plans for mental health care or medical treatment decisions if you are unable to
make them for yourself? Ye s / No
Please check or circle the most correct statement:
___ I have self-referred to the clinic.
___ I was referred to the clinic by_________________________________________________________________________________
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