Assessment

Service Requested

Client Name *

Email *

Date *

Gender *
MaleFemaleNon-BinaryOther

Date of Birth *

Ethnic Identity

Address *

Mobile *

Can I call your mobile? *

Can I text your mobile? *

Emergency contact details: *

Emergency contact telephone: *

GP Name/Doctor: *

Surgery/Address *

Telephone *

Previous experience of therapy? *

Previous experience of psychiatric support? *

Medical History:

Genogram/significant people:

Date of first session: *

Description of what has brought the client to therapy:

What does the client hope to achieve from therapy/client goals?

What has the client done to cope with their problems and how helpful has this been?

YesI agree and accept to the Counselling Agreement.*

Your information will never be shared or sell to anyone.
We respect your private information