Pre-Client Consultation Form - Counselling PRE-CLIENT CONSULTATION FORM - COUNSELLING BIOGRAPHICAL DATA Name * Name First First Last Last Address * Postcode Phone Email * Date of Birth Age Preferred Method of Contact Email Phone Marital Status SingleMarriedDivorcedWidowed Medical Practitioner's Details Referral Name (who referred you) Benestar, MSD, ACC, GP, Womens Refuge, Other) - Employer's Name Length of time employed - Employee # if applicable Employer Location Place of Work Location - Division or Department Section Buttons Next EMERGENCY CONTACT INFORMATION Name Section Buttons Address Contact Phone Number Relationship to you Next MEDICAL HISTORY Please check all that apply None Anemia Anxiety Asthma Blood Clots Cerebrovascular Accident Emphysema Depression Gallbladder Disease PTSD High Blood Pressure Liver Disease Myocardial Infarction Osteoporosis Renal Disease Thyroid Disorder Allergies Angina Arthritis Hypertrophy Cancer Cronary Artery Disease Crohn's Disease Diabetes GERD (Reflux) High Cholesterol Irritable Bowel Disease Migraine Headaches Osteoarthritis Peptic Ulcer Seizure Disorder OtherOther Section Buttons Do you smoke? No Daily Weekly Less Former User Do you drink alcohol? No Daily Weekly Less Former User Caffeine use? No Daily Weekly Less Former User Are you currently taking prescription medication? Please list. Family History Adopted Allergies Arthritis Cancer Depression Diabetes Hearing Deficiency High Blood Pressure Learning Disability Tuberculosis Osteoarthritis Bipolar Alcoholism Asthma Heart Attack Stroke PMS Eczema High Cholesterol Irritable Bowel Disease Anxiety Obesity Osteoporosis Renal Disease OtherOther Next MENTAL HEALTH HISTORY Why you are seeking Counselling? What do you expect from Counselling? Section Buttons Radio ButtonsHave you seen a counsellor, psychologist, psychiatrist or other mental health professional before? Yes No Therapist name and length of time you were seen and what worked for you? Have you ever attempted suicide or experienced suicide idealisation? Please describe your sleep patterns. Please describe what you do for relaxation. Any other additional comments or concerns. Are you interested in Nutritional Support? reCAPTCHA If you are human, leave this field blank. Submit Form to Debbie Buddle
