Free Initial Consultation
All information shared is strictly confidential and will only be viewed by me for the purposes of undertaking your consultation.
Name
Gender
Age
Email Address
Phone Number
Postcode
*** REASONS FOR SEEKING THERAPY ***
What are your reasons for seeking therapy?
In general, how do you feel about your life?
AWFUL
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2
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5
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7
8
9
AMAZING
10
1 is AWFUL, 10 is AMAZING
Why is NOW the time you are seeking therapy?
*** MEDICAL QUESTIONS ***
Are you currently receiving treatment for a mental health related issue?
Yes
No
If yes, please provide details.
Do you feel you have a "mental health condition" (i.e. self-diagnosed)
Yes
No
If yes, please provide details
Have you previously received any type of counselling or psychotherapy?
Yes
No
If yes, how was your experience?
*** GENERAL QUESTIONS ***
How would you rate your physical health condition?
Very Poor
1
2
3
4
5
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7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
How would you describe your general appetite?
Very Poor
1
2
3
4
5
6
7
8
9
Very Hungry
10
1 is Very Poor, 10 is Very Hungry
How would you describe your general stress level?
Not Stressed
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7
8
9
Very Stressed
10
1 is Not Stressed, 10 is Very Stressed
How easy do you find it to fall asleep and wake up?
Very Hard
1
2
3
4
5
6
7
8
9
Very Easy
10
1 is Very Hard, 10 is Very Easy
How well would you say you "look after yourself" emotionally?
Not Very Well
1
2
3
4
5
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7
8
9
Very well
10
1 is Not Very Well, 10 is Very well
How good do you feel about yourself (emotionally)?
1
2
3
4
5
How good do you feel about the way you look?
1
2
3
4
5
How would you rate your romantic life?
1
2
3
4
5
How would you rate your work/career situation?
1
2
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4
5
How would you rate your social life?
1
2
3
4
5
How would you rate your general happiness and well-being?
1
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5
*** APPOINTMENT ***
Please tick your available times for a weekly appointment (tick as many as apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
7am - 8am
8am - 9am
9am - 10am
10am - 11am
11am - 12pm
1pm - 2pm
2pm - 3pm
3pm - 4pm
4pm - 5pm
5pm - 6pm
6pm - 7pm
7pm - 8pm
8pm - 9pm
9pm - 10pm
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