Eve Therapy Client Assessment Form

PERSPECTIVE CLIENT ASSESSMENT FORM

This application forms a part of the assessment appointment that must be completed by the applicant wishing to access our counselling services. Applicants must ONLY complete Section 2, 3, 4, 5, 7 and 9.
1. ASSESSOR DETAILS

Please complete
Date of Assessment

DayMonthYear
Date
Assessment venue

ZoomTelephoneWebsiteOther (please specify)In Person
Title of Assessor?
Name of Assessor?

First NameLast Name
Assessor email should be counselling@evetherapy.com*
example@example.com
2. PERSPECTIVE CLIENT DETAILS:
Client Name:*

First NameLast Name
Date of Birth:*

DayMonthYear
Date
Gender*
Ethnicity*
Client Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
3. NEXT OF KIN CONTACT DETAILS:
Name

First NameLast Name
Relationship to you:
Does your next of kin know that you are in counselling?
Next of kin address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone/Mobile No:
4. GP DETAILS:
GP Practice Name:*
Name of GP:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number - do not add the '0' prefix i.e. 20 3488 1927.
Please enter a valid phone number.
5. PRESENTING ISSUES
What has motivated you to come for counselling at this time?
What are your expectations for therapy?
Have you ever had counselling before?*
If yes, please give details.
Have you experienced any recent or childhood trauma?*

YesNoNot sure
If yes, please give details.
Have you ever been diagnosed with a common mental health condition e.g. depression, anxiety etc.?*

YesNo
If yes, please give details.
Have you ever been diagnosed with a complex mental health disorder? e.g. schizophrenia or Dissociative Identity Disorder etc*

YesNo
If yes, please give details.
Has there been a history of mental health in your family?*
If yes, please give brief details about this diagnosis:
Are you or have you ever taken medication for a mental health disorder?
Please give brief details:
Are you still on medication?
Have you recently thought about about attempting suicide?*
If yes, please give details about about what triggered these feelings?
What led to these thoughts?
Tell me about the history of your problem?
Are there any family issues related to your problem?
If so, what are these issues?
6. SUBSTANCE ABUSE /COMPULSIVE BEHAVIOURS HISTORY
Are you currently struggling with any of the following?

Alcohol AddictionFood AddictionSex AddictionInternet AddictionPornography AddictionMobile/Computer AddictionVideo Games AddictionExercise AddictionDrug AddictionNone
How recently have you engaged in the indicated addictive behaviour?
Why do you think you have this problem?
Only to be read to clients who have presenting issues of addition:
1. To engage in therapy, clients with a history of addiction to drugs which include illegal/mind-enhancing/altering drugs of any kind must agree NOT to consume alcohol, or illegal/recreational drugs, at least 48 hours prior to their session taking place.
2. If the counselling or agency manager finds you to be under the influence of drugs and alcohol, the counsellor/agency manager will cancel the session immediately and you will still be liable for full payment of your counselling session.
3. No further counselling sessions will be scheduled with your counsellor until the agency manager has made contact with you to discuss the incident.
Does the client agree with abstaining? Please note, if the responds by saying 'no', advise the client, that they will not be referred for counselling. However, we can signpost.

YesNoN/A
Please add any additional notes here:
7. SUPPORT
Who is supporting you with your mental health and wellbeing

PartnerParent(s)Sibling(s)Friend(s)Other
If you chose 'other', please identify who it is and how they support you:
8. DEPENDENTS

This MUSTbe completed
Do you have any children:

YesNo
Do you have any current /pending court cases in relation to:

Social ServicesOngoing Child Protection/CasesChild(ren) CustodyDivorceNone of the aboveOther
If you have ticked 'other', please give a brief description.
9. WELLBEING
What do you do for relaxation/recreation?
Has your recreation/relaxation activity decreased?
10. FEES
Are you in paid employment

YesNo
If employed, what is your job title?
What is your level of income?
If unemployed, the client will need to provide evidence of this at your first session.
Assessor - Fee Application
11. SESSION DETAILS

For the Assessor
Counselling Session venue

ZoomTelephoneWebsiteOther (please specify)In Person (Centre)
Preferred day(s) and time(s) the client can attend: PLEASE ENSURE YOU CHECK THE CLIENT DIARY
Thank you for agreeing to answer these question. Please be advised that should you disclose: 1. Harm to Self 2. Harm to others 3. Disclosure of Terrorism 4. Disclosure of Drug Trafficking. Please note Eve Therapy Management will disclose this information to the Agency Supervisor and/or Social Services/Police (whatever is appropriate) Please confirm you understand this? If you do not understand, we will be unable to take this application further.*

YesNoUnsure
12. ASSESSOR CONFIRMATION

For the Assessor
Assessor Name

First NameLast Name
Signature

Clear
Date

DayMonthYear
Date
Should be Empty:

PERSPECTIVE CLIENT ASSESSMENT FORM

1. ASSESSOR DETAILS

2. PERSPECTIVE CLIENT DETAILS:

3. NEXT OF KIN CONTACT DETAILS:

4. GP DETAILS:

5. PRESENTING ISSUES

6. SUBSTANCE ABUSE /COMPULSIVE BEHAVIOURS HISTORY

7. SUPPORT

8. DEPENDENTS

9. WELLBEING

10. FEES

11. SESSION DETAILS

12. ASSESSOR CONFIRMATION