Client Information

First Name

Name

Address

Phone

Date of Birth

Email

GP Name and Address

Have you had counselling or psychotherapy before? Have you had counselling or psychotherapy before? No Yes

Approx. date and duration of previous counselling / psychotherapy

Have you been diagnosed with a mental health issue? Have you been diagnosed with a mental health issue? No Yes

Please elaborate which diagnosis and when diagnosed.

Do you take regular medication? Do you take regular medication? No Yes

Which medication do you take regularly?

Have you had thoughts of suicide or self harm in the last six months? Have you had thoughts of suicide or self harm in the last six months? No Yes

Have you experienced sleep disturbances in the last six weeks? Have you experienced sleep disturbances in the last six weeks? No Yes

Have you felt depression or low mood in the last six weeks? Have you felt depression or low mood in the last six weeks? No Yes

Have you felt anxiety or uncertain fear in the last six weeks? Have you felt anxiety or uncertain fear in the last six weeks? No Yes

How did you hear about my practice?

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