Counselling Questionnaire

Thank-you for booking a consultation with us

Below is our client questionnaire and agreement this must be filled in prior to the consultations, if you do not have time to fill out the form today you will also receive a link to this questionnaire via an email from us.

We will be in touch very soon to schedule our time together. Please remember to fill out the form before our consultation.

We Need Some Info to Help You

Please fill out the following questionnaire. At the end there is space to tell me as much as you like about the issues that you would like to consult about.

Please don’t be put off by the length of the Questionnaire; most of the questions are answered with a yes or a no. The more detailed the answers the better the help that can be provided for you with the best possible service.

Before filling out the questionnaire, a reminder : you must be over 18, and you must have read the legal & privacy agreements. Payment must also be made before you can submit your questionnaire

Questionnaire

First Name

Age

Occupation

Name of GP (Only contacted with your agreement)

Last Name

Gender

Mobile phone (for emergency text messages)

Tel. No. of Surgery (Please include full dialling code)

Email Address

Location

Skype name (for live sessions)

Living Environment

Psychiatric Care - Have you ever had therapy or been in psychiatric care of any kind? If so please give details

Counselling Experience - Give details of any previous counselling experiances

Medication - Have you ever taken or are you currently taking any prescribed medication, (antidepressant, mood stabilizer, sleep medicine, antipsychotic, etc.) Please list medication.

Psychiatric Hospitalisation - Have you ever required psychiatric hospitalisation? If so please give details

Medical Conditions - Are you being treated for any medical conditions? If so, please give details and prescribed medication for the condition.

Significant Change - Have you recently had significant change in your sleep pattern or significant weight loss or gain? Give details

Psychotic State - Have you ever been in a psychotic state - that is, had hallucinations, delusions (like a strong conviction that you're being followed, or that some person is controlling your thoughts)? Have you ever been diagnosed with schizophrenia or paranoia? Give details.

Thoughts of Suicide - Do you have any thoughts of suicide? Or have you ever tried to harm yourself in any way? Give details.

Harm to Others - Do you have any thoughts of doing harm to others? Or have you ever physically hurt anyone? Give details.

Family History - Give a brief family history as a child

Current Family Situation - Give a few details of your current family situation

How would you describe your support system?

If we work together what are you looking for from me?

Encouragement

Support

Challenge

Information

Other(detail in box below)

What Brings you to Therapy - Tell me what brings you to therapy at this time. What kind of issues would you like to talk about? Also, tell me a little about yourself and your background.

I have read & agree to the, Privacy Statement & General Disclaimer in the legal section of this website

Please Select to Show You have Read

Thank you for answering these questions, your answers will help me to offer you the best counselling I can I will be in touch when I have read your answers to arrange your next message

Ron Gathercole