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Name
*
First
Last
Gender
*
Male
Female
Others
Religion
Christianity
Islam
Atheism
Others
Email
*
Current Address
Phone Number
*
Date of Birth
Age
Office Location
Occupation
Home Address
Status
Single
Engaged
Partnered
Married
Separated
Divorced
Widowed
What brings you to therapy currently?
Current Symptoms You Are Experiencing
Physically/verbally aggressive
Overwhelming Stress
Overwhelming Sadness
Feel out-of-control of my Emotions/actions
I am having panic feelings
Recent weight change without Trying
Quick-tempered/easily irritated
I'm having disturbing dreams/ Flashbacks
Recent change in sleep
I feel like destroying things/property
I am very worried/fearful about something
Recent change in sextual desire
I feel impulsive/doing risky behaviours
I feel like I am detached from my own body
Recent change(s) in energy
Easily distracted/having difficulty with focus
I am avoiding situations due to a certain fear
Lack of motivation to do much of anything
I feel I’m hearing voices
I feel no one understands me
I feel my past is catching up with me
I feel I’m being hunted
I am feeling Hopeless
I have obsessions that get in the way of life
I have compulsions that get in the way of life
I’m not comfortable with my body
I feel I’m ugly
Other Symptoms
Do you Exercise?
Yes
No
If Yes, How Often?
If Yes, How Vigorous
Do You Take Caffeine?
Yes
No
1. What Other
If Yes, How Often?
What Type?
Soda
Coffee
Tea
Do you take alcohol?
Yes
No
If Yes, How Often?
Do you currently live alone?
Yes
No
Have you ever attempted suicide?
Yes
No
If Yes, Number of times
Date of last attempt
Do you consider yourself to be religious or spiritual?
Yes
No
If yes, describe your faith or believe
Have you experienced an event or situation in your life that you would consider traumatic?
Yes
No
If yes, briefly describe:
If married, are you having issues in your marriage?
Primary Reason(s) for seeking Therapy currently
Anger Management Issues
Couple’s Relationship Issues
Addiction Issue
Grief and bereavement issue
Anxiety/Stress Coping Feeling of Depression
Addiction Issue
Grief and bereavement issue
Bullying
Family of Origin Issues
Sexual Identity Concerns
Parenting Concerns
Fears/Phobias
Post-War Veteran Concerns
Coping with significant life change
Other(s)
Specific Treatment Goals for Therapy
1.
2.
3.
4.
5.
Any Other Specific Information?
COUNSELLING AGREEMENT
CONFIDENTIALITY
COUNSELLING AGREEMENT
TIME DURATION
TIME DURATION
CANCELLATIONS
CANCELLATIONS
COST OF SERVICE
COST OF SERVICE
PLEASE TAKE NOTE OF THE FOLLOWING SESSION POLICIES
PLEASE TAKE NOTE OF THE FOLLOWING SESSION POLICIES
CONSENT TO TREATMENT (Kindly fill in your name in the space below)
I, ………………………………………………………………………………………, have read Agreement for Services/Informed Consent. In signing below, I consent to treatment and agree to abide by its term during therapy.
Client Name
Date
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