All Things Counselling Assessment Form

First name

Last name

Address (incl. Post Code)

Birthday

Month

Day

Year

Phone

Gender

Occupation

Relationship Status

Children

Have you had any previous counselling? (If so, please provide brief details)

Please describe any physical impairments or limitations which may require special arrangements or may affect the counselling process (i.e. reading difficulties, hearing loss, vision loss, speech impairment, disability):

Medical Details

General Practitioner Contact details

Please detail below any health conditions that couldimpact the counselling process

If you have ever been diagnosed with a mental health condition, please provide details below.

If you have a diagnosed mental health condition, please detail below what medical support/other supports you are receiving

What medications are you currently on?

What is the main issue that you feel counselling could help with?

How did you hear of the Counselling Service?

I confirm that the information I have provided is true to the best of my knowledge. I agree to receiving counselling from a student counsellor in their final year.

Client Signature:

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Client Name:

Date

Month

Day

Year

ASSESSMENT FORM

All Things Counselling Assessment Form

Medical Details