Assessment Form
Psychotherapy, Counseling & Group
Client Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
County
Postal Code
Date of Birth
-
Day
-
Month
Year
Date
Email
example@example.com
Home Phone
Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact
E-mail
Home Phone
Mobile Phone
Relationship Status
Please Select
Single
Married
In a partnership
Divorced
Widowed
Referral Name (if applicable)
First Name
Last Name
Emergency Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Relationship
Insurance Information (if applicable)
Name of Insurer
First Name
Last Name
Insurer Phone Number
Format: (000) 000-0000.
Policy Number
Medical Information
Are you currently taking prescription medication?
Yes
No
Prescribing Doctor's Name and telephone number
Name
Telephone number
If yes, please briefly explain what the medication is:
Have you seen a counselor, therapist, psychologist, psychiatrist or other mental health professional before?
Yes
No
If yes, please briefly explain why and if you found it helpful:
Reason For Services
Is this service for you?
Yes, for me
No, for someone else
If it is not for you, please state who it is for.
Which of the following do you need counselling or therapy for?
Relationships
Anxiety
Addiction
Anger Management
Grief
Self-Esteem
Other
Please explain briefly what the main issues are for seeking counselling?
What are your main goals to be achieved during counselling?
Would you consider remote/online/telephone therapy?
Yes
No
Maybe
When would you like to start?
As soon as possible
In the next few weeks
Other
Please state the best times and days that you would prefer:
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Day
-
Month
Year
Date
Signature
Submit
Submit
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