PRECOUNSELLING FORM: ROOTED IN LOVE

The confidential information you provide below will help me to understand your needs to serve and assist you more effectively and outline how you hope to benefit from our sessions.

All information is provided voluntarily, but you are encouraged to share as much detail as you are comfortable with. You do not need to give long answers, and it is okay to put “I would prefer to talk about this in person” or to leave it blank.

Name *

First

Last

Email *

Contact Number

Physical Address

Date of Birth & Age

Emergency Contact Person :: Full Name & Relationship

Emergency Contact Person :: Contact Number

Emergency :: Is this person aware that you are in therapy *

Yes
No

Family Doctor

Family Doctor 's Contact Number

1. Briefly tell me what are your main reasons for seeking counselling?

2. How long have you been experiencing these difficulties?

3. How do the current difficulties impact on your life at this time?

5. Have you met with a counsellor (or similar professional) in the past? Was that useful?

6. What are your goals for therapy?

7. Are you currently taking any prescribed medication for your difficulties? If so, please provide the name.

6. On a scale of 1-10 (with 10 being the most serious), how seriously is this affecting: Your Life Generally

Selected Value: 0

6. On a scale of 1-10 (with 10 being the most serious), how seriously is this affecting: Your Relationships

Selected Value: 0

6. On a scale of 1-10 (with 10 being the most serious), how seriously is this affecting: Your Work

Selected Value: 0

7. Do you ever experience difficulties with Self-harm

Yes
No

7.1 Do you ever experience difficulties with Thoughts of ending your life

Yes
No

7.2 Do you ever experience difficulties with Over/ Under Eating

Yes
No

7.3 Do you ever experience difficulties with Alcohol and drug use (prescription or other)

Yes
No

7.4 Do you ever experience difficulties with Fears of being harmed by others

Yes
No

7.5 Do you ever experience difficulties with Thoughts of harming others

Yes
No

7.6 Do you ever experience difficulties with Anger/ Aggression

Yes
No

7.7 Do you ever experience difficulties with Low self esteem/ insecurity

Yes
No

7.8 Do you ever experience difficulties with Commitment Difficulties

Yes
No