Client Information Form

This is a copy of the client information form that I send to all prospective clients.

Confidential Information

The information supplied is held in the strictest confidence and will not be disclosed to a third party without your express written consent. Please answer the questions fully.

Today’s date

Name:

Date of Birth:

Address:

Telephone number:
OK to leave messages Y/N

Email:

Occupation:

Married/Single/Divorced/In a relationship/etc:

Who lives with you?

Other significant people in your life:

What are your hopes/expectations of the therapy sessions with me?

Brief outline of the problem

What makes it worse?

If you didn’t have this problem how would your life be different?

Is there anything about the situation that would be helpful for me to know?

 

Current state of health:

Any current or recent medical treatment?

Are you taking any medication? If so, please give details

Have you ever seen a psychiatrist? If so, please give details

GP (Name, Address of Surgery):

Drinking: how many units of alcohol per week?

Smoking: how many per day?

Any other mood-altering substances:

 

When did the problem start?

What steps have you already taken to solve the problem, and with what results?

What stops you from changing?

What will be different once you have changed?

How will this change affect your family and friends?

What has been your best accomplishment to date?

What are the good things in your life at the moment (including any people that support you or activities that you enjoy)?

Any previous experience of therapy/counselling, positive or negative?

 

How did you find out about my services?

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