Garden Gate Therapy Client Goals & Self Assessment

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Name
First Name
Last Name
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Date of Birth
Date
Month
Day
Year
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Today's Date
Date
Month
Day
Year
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Why have you chosen to come to counselling at this time?
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What changes would you like to see?
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Occupation or Employment Details
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GP Name & Address
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What is your relationship status?
Single
Married
Cohabiting
Separated
Divorced
Other
9
If you are in a relationship, how long have you been together?
10
Details of any previous relationships
11
Children
Age
Name
Female/Male
Living With
In Contact With
Adopted/Fostered
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Age
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Name
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Female/Male
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Living With
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In Contact With
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Adopted/Fostered
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Age
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Name
Row 2, Column 1
Female/Male
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Living With
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In Contact With
Row 2, Column 4
Adopted/Fostered
Row 2, Column 5
Age
Row 3, Column 0
Name
Row 3, Column 1
Female/Male
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Living With
Row 3, Column 3
In Contact With
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Adopted/Fostered
Row 3, Column 5
Age
Row 4, Column 0
Name
Row 4, Column 1
Female/Male
Row 4, Column 2
Living With
Row 4, Column 3
In Contact With
Row 4, Column 4
Adopted/Fostered
Row 4, Column 5
Age
Row 5, Column 0
Name
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Female/Male
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Living With
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In Contact With
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Adopted/Fostered
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Do you, or have you had, any physical medical conditions?Please answer yes or no. If yes, please provide dates and details.
13
Do you, or have you had, any mental health conditions?Please answer yes or no. If yes, please provide dates and details.
14
If you answered yes to the last two questions will this effect our sessions?
15
Are you currently taking any medication?Please answer yes or no. If yes, please provide dates and details.
16
Have you had any previous counselling?Please answer yes or no. If yes, please provide dates and details.
17
Have you ever tried to self-harm?Please answer yes or no. If yes, please provide dates and details.
18
Have you ever had suicidal thoughts?Please answer yes or no. If yes, please provide dates and details.
19
Have you ever experienced trauma or abuse?Please answer yes or no. If yes, please provide dates and details.
20
Has alcohol ever been a serious problem for you?Please answer yes or no. If yes, please provide dates and details.
21
Have you, or do you, take recreational drugs regularly?Please answer yes or no. If yes, please provide dates and details.
22
Is there any additional information you would like us to know?
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