(NG) Individuals Counselling Initial Consultation Intake Form

To get the most out of each counselling session, please take a moment to answer the following questions below prior to our session.

These questions are asked in order for me to obtain a greater understanding of your overall life experience. This will assist in facilitate your Counselling Session.

I invite you to be open and honest in your answers.

Name

First Name

Last Name

D.O.B

Age

MEDICAL HISTORY

Is there any relevant medical history that you believe is important for your counsellor to be aware of?

Yes

If yes, Please give further detail

Briefly describe your general health (exercise, eating habits, sleep duration & quality)

MENTAL HEALTH HISTORY

Have you seen a practitioner, psychologist, counsellor for previous issues?

Yes

If yes, please briefly list when this occurred and for what issues.

Have you been diagnosed with a Mental Health Condition?

Yes

If yes, Please give further detail including any medications

Have you ever had any thoughts of harming yourself?

Yes

If yes, Please give further detail

How have you coped with previous life issues and troubles?

YOUR UPCOMING SESSION

What are the issues/concerns that bring you to counselling?

What do you hope to achieve from your counselling sessions?

On a scale of 1-10, how committed are you to engaging in the counselling process? (10 being highly committed)

Is there anything else you would like me to know?