Psychiatric & Counseling Services Form

Virtuous Healthcare Practice & Virtuous Cross Counseling Personal & Mental Health Assessment Form:
Welcome to Virtuous Healthcare Practice & Virtuous Cross Counseling. We are dedicated to providing compassionate, personalized counseling services tailored to your unique journey. Our approach is built on a strong, supportive relationship between you and your provider, as we believe this connection is essential in the healing process.

We recognize that every individual experiences life, challenges, and healing differently. Rather than following a one-size-fits-all model, we focus on empowering you by exploring solutions that work best for you. This form will help us understand your personal experiences, particularly around anxiety and any other concerns that may be impacting your well-being. Your responses will guide us in developing a plan that supports your growth in a way that aligns with your needs and strengths.
Client's Rights
1. The client may ask questions on what to expect during and end result of the therapy.
2. The client may decline to proceed the therapy as to the techniques which may be conducted by the therapist.
3. The client may cease to continue therapy anytime, without any impediment and may return to therapy anytime.
4. The therapist has the right to dismiss the client from the course of therapy.
5. The client has the right to review his or her records from the therapist.
6. Right to confidentiality: Within limits provided for by law, all records and information acquired by the therapist shall be kept strictly confidential in accordance to the principles of a doctor-patient relationship. All information will not be shared or revealed to any person, agency, or organization without the prior written consent of the client. Although according to the harm principle, if there is a situation where there is domestic violence, self harm or harm for others, therapist has the right to contact the necessary institutions.
7. Referrals: If client has a particular concern needing a specialized treatment approach (e.g. a couples therapy, EMDR therapy, family therapy, sex therapy, alcohol or drug problems specialist etc.), therapist has the right to refer the client to an other specialist in the field.
8. Consultation: Anonymous supervision will be carried out with therapist's supervisor.
9. The client can raise any concerns and to speak with the therapist immediately of any concerns provided that the therapist is likewise available to discuss matters with the client.
Please check the items that you believe is affecting you

Anger or hostile feelingsAnxiety and fearsSadness or Low MoodFamily issuesProcrastinationPhysical distressRelationship/marital concernsShynessTraumatic experiencesSocial conflictsSuicidal feelings or behaviorsStress and nervousnessSleep disorderSelf-controlSelf-esteem or confidenceWork or career concernsSexual ConcernsDCF Issues
Can you describe what brought you here today and how you're feeling?
Have you experienced any major changes in your mood, sleep, appetite, or daily activities?
Do you have any thoughts of harming yourself or others?
Have you been diagnosed with any mental health conditions before or received any previous treatment?
How is your current situation affecting your relationships, work, or daily life?
Can you walk me through a typical day for you? What are the most difficult moments, and when do you feel most at ease?
When did you first start noticing these symptoms, and have they changed over time?
How do you usually cope with stress or difficult emotions? Have you noticed any unhealthy coping mechanisms, such as substance use or self-harm?
Have you had any significant life events, trauma, or losses that might be contributing to how you're feeling now?
What are your goals for seeking treatment? What changes would you like to see in your mental health and daily life?
Do you experience physical symptoms like rapid heartbeat, sweating, or difficulty breathing when anxious?
Do you struggle with motivation or find yourself losing interest in things you once enjoyed?
Do you ever have thoughts of harming yourself or feel like life is not worth living?
What are you hoping to accomplish during your intial visit?
Acknowledgement

I have reviewed this Professional Counseling Informed Consent Agreement. I likewise understand my Client's Rights set in this form.

I accept this agreement and consent to counseling.
Client Name

First NameLast Name
Email
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Phone Number

Area CodePhone Number
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Signature

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Date Signed

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Virtuous Healthcare Practice & Virtuous Cross Counseling Personal & Mental Health Assessment Form: