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Counselling Initial Assessment Form

Gathers a new client's personal, contact, and health information ahead of the first session, along with their goals and preferences for therapy.

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Client Name

First Name

Last Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Date of Birth

Home Phone

Mobile Phone

Preferred Method of Contact

Phone Email Text Message

Relationship Status

Referral Name (if applicable)

First Name

Last Name

Name

First Name

Last Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

Relationship

Name of Insurer

First Name

Last Name

Insurer Phone Number

Policy Number

Are you currently taking prescription medication?

Yes No

Prescribing Doctor's Name and Telephone Number

First Name

Last Name

If yes, please briefly explain what the medication is:

Have you seen a counsellor, psychologist, psychiatrist or other mental health professional before?

Yes No

If yes, please briefly explain why and if you found it helpful:

Is this counselling for you?

Yes No

If it is not for you, please state who it is for.

Which of the following do you need counselling or therapy for?

Anxiety Depression Relationship issues Grief Stress Other

Please explain briefly what the main issues are for seeking counselling?

What are your main goals to be achieved during counselling?

Would you consider remote/online/telephone counselling?

Yes No Maybe

When would you like the counselling to start?

As soon as possible Within a week Within a month No rush

Please state the best times and days that you would prefer:

Additional Comments or Concerns

By signing below, I declare that the information included in this form is truthful and complete

Date

Signature

Sign here

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