Confidential Initial Assessment Information Questionnaire

Full Name*

First NameLast Name

What is your age?

What is your gender?*

Contact Number*

Area CodePhone Number

Email Address*

example@example.com

Select this option if you would NOT like to recieve offers and promotions via Email

Where did you hear about me?

Doctors name and surgery address?

Are you currently taking any medication?*

YesNo

Please list them, what it is for, and dosage.

Do you have any further medical conditions that aren't mentioned above?*

YesNo

Please list them.

Have you been to see a psychiatrist, counsellor, psychologist or other type of therapy?*

YesNo

Please give details.

Are you married or with a partner?

Do you have children?

Have you experienced any major bereavements?

Who do you live with and how is your relationship with them?

Who was in your family system when you were growing up and what was your relationship like with them?

Check the Items below that indicate a problem to you:*

Please give details about what you would like to achieve from your session.

Therapy Information and Agreement

Contact Information: My name Lee Keeble. I can be contacted through my mobile 07580077957 or by email: contact@leekeeble.com.

Contact between allocated sessions is usually limited to appointment changes only. I am not trained in crisis counselling and am therefore not able to offer a crisis service. Please make contact with your GP or A&E if you are in crisis. In addition, the Samaritans offer a free 24 hr, 365 day crisis service, they can be contacted on 116 123 or text Shout 85258

Confidentiality: Please see my privacy policy for more detail on your data. Your sessions are confidential and I will not share any information without your permission unless I believe you are in danger to yourself or others and unable to negotiate with me, for safeguarding and when required by law which includes terrorist action and money laundering (please see exceptions below for more information). If I see you somewhere outside of our sessions, to ensure your confidentiality, I will not approach you or act as if I know you, however if you acknowledge me then I will acknowledge you. Although the therapeutic relationship is friendly it is not the same as friendship, so in order to keep our therapeutic space the confidential and safe experience that you deserve, I avoid any kind of dual relationship with current and former clients.

Exceptions apply as detailed below;

Information about a child or adult, who I believe, is, or who may be at risk of, significant harm. I will seek to respect your wishes unless this may compromise the safety of the person at risk. If you disclose planned serious harm to yourself or others. I will encourage you to speak to others, such as your GP, but I may consider acting on your behalf and this may be without your consent. (And this also may be after our sessions have ended if the ending is unplanned). If you tell me information about offences as required by law. A Judge also has the power to subpoena counselling notes in the event of a court case.

Session Notes: I do keep short notes from our sessions. These notes are kept confidential and are stored under a coded system in a safe and secure place.

Cancellation / Late Attendance: Please give us as much notice as possible for the cancellation of appointments so that we can fill your slot. If you need to cancel or amend your appointment for any reason our cancellation policy is:

More than 48 hours notice - no fee / Between 24-48 hours - £25 / Between 0-24 hours – full fee
If you are late for your appointment, we will still need to finish by the allotted time.

Antisocial behaviour will cause the immediate cessation of treatment.

Client Signature: I have read the above 'Therapy Information and Agreement' and understand what i have read.*