Adult intake form

Welcome to TicTock Therapy

We provide specialist support for adults experiencing tics or Tourette-related presentations, using structured nervous system and skill-based approaches.

Please complete this form so we can recommend the most appropriate support pathway.

SECTION 1 – Personal Details

Full Name

Date of birth

Day

Month

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Occupation

Contact Email

Contact Phone Number

GP name and surgery

SECTION 2 – Presenting Concerns

What prompted you to seek support at this time?

When were tics first noticed?

How have tics changed over time?

Please describe current tics as a list (motor and/or vocal).

On a scale of 0–10, how severe are tics currently?

SECTION 3 – Premonitory Urge & Suppression

Do you experience a premonitory urge? (a build up prior to ticcing)

Can you suppress tics temporarily?

What happens after suppression?

Does suppression cause distress or fatigue?

Do you mask or hide tics socially?

SECTION 4 – Emotional & Nervous System Profile

Describe the emotional impact in your own words.

SECTION 5 – Neurodevelopmental & Medical History

Current Medication

Previous Therapy

SECTION 6 – Functioning & Goals

1. How are tics currently affecting your daily life?

2. What would feel different in 3 months if support was successful?

3. What is your biggest worry right now?

4. On a scale of 1–10, how urgent does this feel?

SECTION 7 – Commitment

Our approach typically begins with a structured 6-session foundation programme. Are you willing to commit to a structured programme?

Yes

Unsure

Not at this stage

Adult Intake Form

Adult Intake form