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CONFIDENTIAL CLIENT ASSESSMENT FORM
PERSONAL INFORMATION
First Name:
*
Last Name:
*
Date of Birth:
*
Gender:
*
Male
Female
Other
Address:
*
Phone #:
*
Email:
*
Occupation:
*
I am a private client
I am an NDIS participant
NDIS Number:
*
Plan Management:
*
Self Managed:
*
Plan Managed by:
*
Contact Person:
*
Email:
*
Phone Number:
*
Nominee Contact Details (if applicable)
Contact Person:
Email:
*
Phone Number:
*
EMERGENCY CONTACT INFORMATION
Name:
*
Relationship:
*
Phone #:
*
GP Details:
*
KINDLY RESPOND TO THE QUESTIONS BELOW
Your input is confidential and crucial for customizing our services to your needs and fulfilling my duty of care. Feel free to share any information about your mental health and general well-being that you are comfortable disclosing. Please return this form before or during our initial session.
1. Have you received counselling or psychotherapy before?
No
Yes
If yes, briefly describe the reason and length of treatment:
Fill all required fields
*
CONFIDENTIAL CLIENT ASSESSMENT FORM
2. How would you rate your current physical health?
Poor
Satisfactory
Good
Excellent
Please list any specific health concerns or conditions you are currently experiencing:
3. Are you taking any medications?
Yes
No
If yes, specify medication, diagnosis, and duration:
4. What is your current alcohol consumption?
Never
Seldom
Less than twice a week
More than twice a week
If applicable, how does it affect you?
5. Do you smoke?
Yes
No
If yes, how many cigarettes a day?
6. Do you exercise?
Never
Seldom
Less than twice a week
More than twice a week
7. Do you have any hobbies?
Yes
No
If yes, please describe:
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CONFIDENTIAL CLIENT ASSESSMENT FORM
8. How would you rate your current sleeping habits?
Poor
Satisfactory
Good
Please describe if you are experiencing any specific sleep problems:
9. What feelings have you been experiencing, and what is each one about?
FEELING
ABOUT
RATE THIS FEELING ON
A SCALE OF
0 - 10
SINCE WHEN HAVE
YOU FELT THIS WAY
Tired
Yes
No
Nervous
Yes
No
Hopeless
Yes
No
Restless
Yes
No
Anxious
Yes
No
Depressed
Yes
No
Fearful
Yes
No
Angry
Yes
No
Frustrated
Yes
No
Disgusted
Yes
No
Lonely
Yes
No
Vulnerable
Yes
No
Resentment
Yes
No
Shame
Yes
No
Grief
Yes
No
Guilt
Yes
No
Sad
Yes
No
Low Self-worth
Yes
No
Despair
Yes
No
Overwhelm
Yes
No
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CONFIDENTIAL CLIENT ASSESSMENT FORM
10. Are you currently experiencing panic attacks, or phobias?
Yes
No
If applicable, please describe your experience:
11. Have you recently faced significant life changes or stress?
Yes
No
If applicable, please describe your experience:
12. Do you remember your dreams?
Yes
No
If applicable, please describe your experience:
13. Share details about your religious or spiritual beliefs?
14. What provides support for you during challenging times?
15. What are your expectations or goals for engaging in this work?
16. Which method works best to express yourself?
Talking:
Yes
No
Writing:
Yes
No
Drawing
Yes
No
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CONFIDENTIAL CLIENT ASSESSMENT FORM
17. With your approval, aromatherapy is part of the process.
Yes
No
Are you comfortable with the integration of essential oils?
18. How did you hear about us?
Google search
Social media
Word of mouth
Referral from a friend
Referral from family
Referral from a colleague
Website
Other (please specify)
Date of Initial Consultation:
Time:
IMPORTANT NOTE:
To avoid incurring the full fee, it is essential to notify Monica of any appointment modifications or cancellations at least 48 hours before the scheduled session. Your cooperation is greatly appreciated. Thank you.
PARTICIPANT AND/OR LEGAL GUARDIAN AUTHORIZATION
Name:
Date:
Signature:
*
YOUR NOMINEE/LEGAL GUARDIAN
Name:
Date:
NOTE:
Kindly wear comfortable clothing and remember to bring thick socks or slippers for use inside. Shoes are to be left outside.
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*
RELATIONSHIP MAP
Please fill in the names of relevant relationships in your life, both positive and negative.
You
Partener
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