Assessment Form

Counselling & Psychotherapy Assessment Form

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

We have tried to keep things as simple as possible. Please answer all questions as fully as possible.

Gender:
Male Female

Who can we contact in case of emergency? E.g friend, family member, general practitioner. Please include a telephone number.

Note: We will not normally contact this individual and will only do so if we assess you as being at serious risk. In the unlikely event that we need to contact him/her, we 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.

Relationship Status

Do you have children?
Yes No

Are you CURRENTLY prescribed or taking ANY form of medication? (This does not include over-the-counter preparations.)
Yes No

Note: It is important that we know about all substances which might have an effect on your mood both during and outside sessions. All information provided here is held confidentially.

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".

How would you describe your reason for attending counselling ?

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

Note: It is important that we know about all substances which might have an effect on your mood both during and outside sessions. All information provided here is held confidentially.

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".

Are you CURRENTLY receiving any form of counselling psychological therapy or psychiatric help?
Yes No

If you answered Yes to the above question, 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 are receiving. If you answered No, please type N/A. *

Do you use recreational substances other than alcohol?
Yes No

Note: It is important that we know about all substances which might have an effect on your mood both during and outside sessions. All information provided here is held confidentially

If you answered Yes to the above question, please detail or list the type of help you are receiving. If you answered No, please type N/A. *

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

For more information please complete this form or download it here and send it to davidlloydlcs@gmail.com!