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Counselling Assessment Form
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Name
*
First
Last
Date of Birth
*
Email Address
*
Preferred Pronouns
She/Her
He/Him
They/Them
Other
Preferred Method of Contact
*
Text Message
WhatsApp
Email
Phone Call
Frequency of Sessions
*
Weekly
Fortnightly
Monthly
Quaterly
Emergency Contact
*
GP Contact Details
*
Current Medications/Treatments
*
Reasons for Seeking Counselling
*
Current Circumstances (Work/Home life)
*
Any Thoughts of Life Not Worth Living?
*
Yes
No
How Intense is Your Emotional Distress? (0 – Not at all, 10 – Incapacitating
Emotional Distress:
0
To what degree do your problems affect your ability to perform at work, at home, and in your relationships with others? (0 – Not at all, 10 – Incapacitating (copy)
Impact on Performance:
0
Any Self-Harming Behaviours?
*
Yes
No
Weekly Substance/Alcohol Use
*
None
1-2 Occasions
3-4 Occasions
5+ Occasions
What Are Your Expectations of Counselling?
*
Intense Behaviours? Incapacitating
Anything Else you Want to Tell Us?
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