Pre-Therapy Assessment Form:

Personal Details:First Name:                     Surname:                         

Age:           Gender (select one):

Country of Residence:                          Ethnicity:                               Is English your first language?

Marital Status (select one): Married Separated Single Widowed Divorced Long-term/Civil Partnership

Employment Status (select one): Employed (full time) Unemployed Employed (part time) Retired Self-employed Student

Occupation (if applicable):                     

Which of the following best describes your living situation? (select as many as applicable):Living alone Living with partner Caring for children under 5 Caring for children over 5 Living with parents/guardians Living with other family or friendsFull-time live-in carer Living in shared accommodation Living in institution or hospital Living in temporary accommodation

(eg. hostel)

Other                          

Your Contact Details:Telephone (mobile):                Telephone (home):                Are you comfortable with voice messages being left on your mobile? YES NO Email:                               Home Address:                    

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Male FemaleNon-Binary

Yes No

General Practitioner (GP) Details:Practice Name:                Doctor’s Name:                Telephone:                 Address:                     

Emergency Contact:Emergency Contact Name:                Relationship to you:                Telephone (mobile):                Telephone (home):                

Medical History:Do you have any medical conditions you feel are relevant or that you’d like me to know about?                                                                                                     Are you currently under the treatment of a psychiatrist or other mental health professional?

Please specify:                               

Are you currently prescribed/taking any psychiatric medications (antidepressants, mood stabilizers, antipsychotics, etc.)? Please Specify:                               

Appointment Preferences:What type of counselling support are you seeking? (select one)

Zoom (video) Email Correspondence onlyZoom (audio only) Live Chat (via Zoom) only

What is your availability? (check all that apply)

Monday Tuesday Wednesday Thursday Friday

Morning Morning Morning Morning Morning

Afternoon Afternoon Afternoon Afternoon Afternoon

Evening Evening Evening Evening Evening

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Yes No

Yes No

What brings you to therapy?Please briefly describe what brings you to therapy:

                              

Please briefly describe how you feel therapy might help you:                              

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Please select any of the following concerns that are relevant for you:

depression life transitions

family issues

violence/victim support problems with

food/disordered eating

shyness/social phobia abuse

panic attacks anxiety feeling stressed or overwhelm

ed

bereavement/ death of a loved one

trauma thoughts of suicide

medical illness

anger addiction low moodfeeling

emotionally numb/ empty

sexuality

body image

PTSD (post-traumatic

stress)

low self-esteem

problems at work or school

self-harm troubled relationships

trouble relating to others

risky behaviour

self-discovery

gender identity childhood issues

nightmares paranoia fears/

phobias general unhappiness

terminal illness

Thank you for taking the time to complete this form.Please send your completed form to me at cloieparfitt@gmail.com.

To protect your information, I strongly suggest you password protect this document with the following password: CPTherapy20

You can find a guide on password protecting Word documents on the “Questions” section of my website.

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