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Menu
Home
About
About TRIA
Our Vision & Mission
Podcast: The Relational Approach
Events
Student Zone
Post Grad Gestalt Training
Post Graduate Training In Contemporary Gestalt Therapy
Our Policies
Get Therapy
BOOK NOW
Community Clinic
Foundational Gestalt Training
Blog
Contact
Client Assessment Form
Please fill out this form prior to coming for your first session.
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
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
X
