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Pre-Therapy Assessment Form:
Personal Details:First Name: Surname:
Age: Gender (select one):
Country of Residence: Ethnicity: Is English your first language?
Marital Status (select one): Married Separated Single Widowed Divorced Long-term/Civil Partnership
Employment Status (select one): Employed (full time) Unemployed Employed (part time) Retired Self-employed Student
Occupation (if applicable):
Which of the following best describes your living situation? (select as many as applicable):Living alone Living with partner Caring for children under 5 Caring for children over 5 Living with parents/guardians Living with other family or friendsFull-time live-in carer Living in shared accommodation Living in institution or hospital Living in temporary accommodation
(eg. hostel)
Other
Your Contact Details:Telephone (mobile): Telephone (home): Are you comfortable with voice messages being left on your mobile? YES NO Email: Home Address:
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Male FemaleNon-Binary
Yes No
General Practitioner (GP) Details:Practice Name: Doctor’s Name: Telephone: Address:
Emergency Contact:Emergency Contact Name: Relationship to you: Telephone (mobile): Telephone (home):
Medical History:Do you have any medical conditions you feel are relevant or that you’d like me to know about? Are you currently under the treatment of a psychiatrist or other mental health professional?
Please specify:
Are you currently prescribed/taking any psychiatric medications (antidepressants, mood stabilizers, antipsychotics, etc.)? Please Specify:
Appointment Preferences:What type of counselling support are you seeking? (select one)
Zoom (video) Email Correspondence onlyZoom (audio only) Live Chat (via Zoom) only
What is your availability? (check all that apply)
Monday Tuesday Wednesday Thursday Friday
Morning Morning Morning Morning Morning
Afternoon Afternoon Afternoon Afternoon Afternoon
Evening Evening Evening Evening Evening
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Yes No
Yes No
What brings you to therapy?Please briefly describe what brings you to therapy:
Please briefly describe how you feel therapy might help you:
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Please select any of the following concerns that are relevant for you:
depression life transitions
family issues
violence/victim support problems with
food/disordered eating
shyness/social phobia abuse
panic attacks anxiety feeling stressed or overwhelm
ed
bereavement/ death of a loved one
trauma thoughts of suicide
medical illness
anger addiction low moodfeeling
emotionally numb/ empty
sexuality
body image
PTSD (post-traumatic
stress)
low self-esteem
problems at work or school
self-harm troubled relationships
trouble relating to others
risky behaviour
self-discovery
gender identity childhood issues
nightmares paranoia fears/
phobias general unhappiness
terminal illness
Thank you for taking the time to complete this form.Please send your completed form to me at [email protected].
To protect your information, I strongly suggest you password protect this document with the following password: CPTherapy20
You can find a guide on password protecting Word documents on the “Questions” section of my website.
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