Client Assessment Form

Contact Details

First Name*

Surname

DOB

Age

Email*

Address

Phone Number

Current Occupation

Emergency Contact

Someone who could be called if you needed support after a session. Please include full name and phone number.

How did you hear about our affordable therapy?

Medical History

1. What are your main concerns/reasons for considering therapy?

2. Have you had any previous counselling or psychotherapy? If yes, reason & length of treatment?

3. Have you ever seen a psychiatrist? Have you been given a diagnosis?

4. Are you currently taking any medications?

5. Have you ever had, or do you currently experience suicidal thoughts or self harm?

6. Are you currently feeling suicidal?

7. Do you or have you had in the past any concerns regarding addiction? If yes, with what, for how long?

General Health

Do you have any specific health problems you are currently experiencing?

What is your weekly consumption of ALCOHOL?

Never
Seldom
Less than twice a week
More than twice a week

What is your weekly consumption of CIGARETTES?

Never
Seldom
Less than twice a week
More than twice a week

What is your weekly consumption of RECREATIONAL DRUGS?

Never
Seldom
Less than twice a week
More than twice a week

Session Details

1. When are you available to attend sessions (which days/which times)?

All sessions are confidential however as part of their training, our therapists are required to video record sessions. After being viewed by a supervisor, the video is deleted. At your initial session you will be asked to sign a consent form that outlines the details of this.

2. Do you understand that any sessions held with our therapists may need to be videotaped for training & supervision purposes?*

Yes, I understand my session may be taped
No - please tell me more information

FEES: Sessions are $40- $80 (sliding scale depending of your income) or $30 for unemployed. What amount is affordable for you?

Contact Details

Medical History

General Health

Session Details