My Dedicated Counselling Service Intake Form

My Dedicated Counselling Service Intake Form
Welcome to My Dedicated Counselling Service. We ask for your cooperation in filling out the following form, completing every questions and adding N/A (non-applicable) for any questions you would rather not answer or does not apply to you.

The forms take around 15 minutes of your time to complete. This information is vital as it will enable us to find the most suitable counsellor for you. All the information provided is confidential and is NOT shared with any third party.
GENERAL INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post Code / Zip Code
Gender*

MaleFemale
Date of Birth*

DayMonthYear
Date
Email*
example@example.com
Phone Number*

Area CodePhone Number
May we leave messages ?*
Current Marital Status*
Who referred you or how did you hear about us?*
What other support do you feel you have at the moment?*
HEALTH AND SOCIAL INFORMATION
How is your physical health at present?*
Are you currently receiving psychiatric services, professional or any other support services?*

YesNo
If yes, when were you treated and for what problems?*
Are you currently taking prescribed psychiatric medication (antidepressants or others)?*

YesNo
If Yes, please list:*
If no, have you been previously prescribed psychiatric medication?*

YesNo
If Yes, please list:*
How often do you drink alcoholic beverages?*
How often do you use recreational drugs?*
If occasionally, frequently or heavily, please give more details.*
If other, please explain briefly*
Have you had suicidal thoughts recently?*
Have you had suicidal thoughts in the past?*
Have you ever been hospitalised for drug or alcohol abuse, a suicide attempt, 'nerves' or other mental health concern?*
If 'Yes' please give dates and circumstances*
Please list any persistent physical symptoms or health concerns (e.g. chronic pain,headaches, hypertension, diabetes, etc.):*
OCCUPATIONAL, LEGAL INFORMATION
Are you employed?*

YesNo
If yes, are you happy at your current position?*
Please list any work-related stressors:*
Are you currently involved in any legal actions?*

YesNo
If yes, or other please explain:*
GP Details

We require your GP's. details to comply with good practice standards and will not contact your GPwithout discussing it with you first.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / County

Post Code / Zip Code
Phone Number*

Area CodePhone Number
EMERGENCY

Next of kin/ Person to alert in the event of medical emergency: (Optional)
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
COUNSELLING
Are you currently being treated by a therapist, psychotherapist or counsellor?*

YesNo
Have you previously had counselling/psychotherapy?*
If yes, describe type, length of time, how long ago?*
When are you available for weekly appointments?*
PRESENTING ISSUES AND GOALS
Briefly describe the situation/circumstances for which counselling is being sought.*
What are your goals for counselling or what are you hoping to change?*
Please tell us any additional background information you feel would be helpful for your counsellor to know:*
SESSIONS & PAYMENTS
Sessions are conducted online or via telephone only, the fee is £65 per session.
Please, add your signature below using your mouse.
Client Signature *

Clear
For Office use only.Admin notes:
Counselling notes:
Should be Empty:

My Dedicated Counselling Service Intake Form

GENERAL INFORMATION

HEALTH AND SOCIAL INFORMATION

OCCUPATIONAL, LEGAL INFORMATION

GP Details

EMERGENCY

COUNSELLING

PRESENTING ISSUES AND GOALS

SESSIONS & PAYMENTS