Name
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First Name
Last Name
Email
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Phone
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(###)
###
####
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
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MM
DD
YYYY
Gender
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Relationship
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Engaged
Married
Partnership
Remarried
Separated
Single
Widowed
What is your highest education?
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Primary School
High School
Diploma
Bachelor Degree
Master Degree
PhD
Honours Degree
Certification
No schooling
What is your occupation?
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Select what has brought you to counselling
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Abuse
Addiction
Child & Adolescent Behaviour
Child & Adolescent Counselling
Effective Parenting
Family Therapy
Grief & Loss Counselling
IVF Counselling
Mindfulness
Personal Growth Support
Professional Growth Support
Relationship Couples Counselling
What is your main concern/issue/problem that you would like to discuss? Just in a few sentences.
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Do you have (step)children?
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What is their first name?
Age children
Are the children in your care?
Yes
No
Custody agreement
Foster Care
With adoptive parents
Living with other family members parttime or fulltime
Other..
Have you seen a counsellor, psychiatrist, GP or psychologist before? (or any other relevant health practicioner)
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What was the reason for seeing this health professional?
Have you ever been diagnosed with a mental health condition (e.g. anxiety, depression, PTSD, etc.)?
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As part of understanding how best to support you, it is helpful to know which mental health conditions you are experiencing. Please mention them below.
I can sleep through the night?
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I wake up multiple times every night
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I have vivid dreams / nightmares
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I am feeling rested in the morning
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I have difficulty falling asleep
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I have difficulty getting out of bed
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I can do all my daily house chores effortless
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I cook a fresh meal every day for myself and/or family
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I have a hygienic routine every day (e.g. showering, brushing teeth)
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I have at least 1 good friend
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I enjoy socialising
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I go out a lot to meet friends/family
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I would like to sleep all day
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I would enjoy to join a local support group of my interest
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I have persistent loss of interest in previously enjoyed activities
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I am withdrawing from other people
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I have been feeling down
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I feel rapid mood changes (mood swings)
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I have outbursts of anger
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I have episodes of anxiety
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I feel a frequent feeling of guilt
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I have a difficulty leaving home (social anxiety)
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I have a fear for certain object or situations (e.g. flying, heights, animals)
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I find myself repeating things (e.g. counting, checking doors, washing hands)
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I spend a lot of time alone
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I have moments that I feel numb
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I feel irritated at times
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I feel at times worthless
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I feel often sadness
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I feel often fear
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I feel often hopelessness
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I feel or act like a different person at times
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I do not feel hungry
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I am eating more
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I feel an urge to vomit after eating
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I eat vegetables and fresh fruit every day
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I follow a diet
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I would like to change my diet to gain or lose weight
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I experience difficulty catching my breath
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I experience sweating more than usual
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I experience a decreased level of energy
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I have tremors (e.g. eye tremors, hand)
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I feel frequently worried
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I have racing thoughts
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I experience muscle tensions
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I feel often dizzy
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I feel fatigued
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I have regular flashback of events
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I am often forgetful
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Are there any other symptoms that you are experiencing?
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Thank you for taking the time to prepare for your consultation. Would you like to add or share something else that you consider important?
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