Before we can start to work together in the way you choose I need you to complete this confidential online assessment form...

I use this form to learn a little about you and the problem you are bringing to counselling. I have found it saves a great deal of time when it comes to a first session and prevents me from having subject you to a stream of questions at a time when perhaps nervousness prevents you from thinking straight!

Although its length may appear a little daunting, I have tried to keep things as simple as possible. Please answer all questions as fully as possible.

First name

Last name

Email address

Gender: male female

Age:

County/state or province and country:

Religion, if any:

Who can I contact in case of emergency - friend, family member, general practitioner, and their telephone number?
I will not normally contact this person and will only do so if I assess you as being at serious risk. In the unlikely event that I need to contact him/her, I will only do so on a "need to know basis" and wherever possible, in consultation with you:

Are you in paid employment? Yes No
Please describe your occupation, paid or unpaid. If you are currently unemployed, please outline your former occupation or job for which you are trained:

What is the highest level of education or training you have achieved?


Relationship status:

Additional living companions:

Do you have children? Yes No
Do you have step-children/children of your partner? Yes No
Are you responsible for the day-to-day care for anyone other than your own children or those of your partner?
Yes No

Are you CURRENTLY prescribed or taking ANY form of medication? (does not include over-the-counter preparations.)?
Yes No
If you answered Yes to the above question, please list your medications, indicating what they are used for. If you answered No, please type "N/A":


Have you EVER been prescribed or taken any any medication associated with mood disorder, depression, anxiety, mental health or sleeping problems? (This does not include over-the-counter preparations.) Yes No
If Yes then please list below - it is important that I know about all substances which might have an effect on your mood both during and outside sessions. All information provided here is held confidentially:

Are you CURRENTLY receiving any form of counselling, psychological therapy or psychiatric help? Yes No
If Yes please detail or list the type of help you are receiving. If you answered No, please type N/A:



Have you EVER received any form of counselling psychological therapy or psychiatric help at any time in the past? Yes No
If you answered Yes to the above question, please detail or list the type of help you received. If you answered No, please type N/A:

Please list any NON-psychological therapies you are currently receiving e.g osteopathy, acupuncture, massage etc. If none, please type N/A:

How much alcohol (if any) do you drink each week? If none, please type N/A:

Do you use recreational substances other than alcohol? It is important that I know about all substances which might have an effect on your mood both during and outside sessions. All information provided here is held confidentially. Yes No

If you answered Yes to the above question, please list the substances you use, indicating how much and how often. If you answered no, please type "N/A:

 

Please describe your relationship with food, including any cravings, under or over-eating, eating patterns in relation to mood etc:

How many hours per day do you spend online?

FB

YouTube

Gaming

Browsing

Texting

Work/School

Other

Do you feel your use of technology is balanced and healthy, or could it be improved? Please explain:

Are you diabetic? Yes No

Please detail any major illness or condition, including disability you are experiencing or have experienced in the past:

Brief family history as a child - nature and quality of your relationships with members of your family:

Describe your problem. What do you fear most about your present situation?

What you are hoping to achieve from counselling?

Which of the following options best describes the daily level of support available to you?

Non-existent

Poor

Adequate

Fluctuates

Pretty good

Excellent

Which of the following options is your preferred method for conducting counselling sessions?

Email

Video chat

Audio chat (PC to PC call)

Text based chat (instant messaging)

Telephone call

Face to face

 

Thanks for completing this form - just click on the send button and I'll be in touch with you shortly.