Garden Gate Therapy Client Goals & Self Assessment

1
Name
First Name
Last Name
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2
Date of Birth
Date
Month
Day
Year
Date
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3
Today's Date
Date
Month
Day
Year
Date
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4
Why have you chosen to come to counselling at this time?
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5
Occupation or Employment Details
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6
GP Name & Address
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7
What changes would you like to see?
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8
What is your relationship status?
Single
Married
Cohabiting
Separated
Divorced
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9
If you are in a relationship, how long have you been together?
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10
Details of any previous relationships
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11
Children
Age
Name
Female/Male
Living With
In Contact With
Adopted/Fostered
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2
3
4
5
6
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2
3
4
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Age
Name
Female/Male
Living With
In Contact With
Adopted/Fostered
Age
Name
Female/Male
Living With
In Contact With
Adopted/Fostered
Age
Name
Female/Male
Living With
In Contact With
Adopted/Fostered
Age
Name
Female/Male
Living With
In Contact With
Adopted/Fostered
Age
Name
Female/Male
Living With
In Contact With
Adopted/Fostered
Age
Name
Female/Male
Living With
In Contact With
Adopted/Fostered
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12
Do you, or have you had, any physical medical conditions?Please answer yes or no. If yes, please provide dates and details.
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13
Do you, or have you had, any mental health conditions?Please answer yes or no. If yes, please provide dates and details.
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14
If you answered yes to the last two questions will this affect our sessions?
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15
Are you currently taking any medication?Please answer yes or no. If yes, please provide dates and details.
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16
Have you had any previous counselling?Please answer yes or no. If yes, please provide dates and details.
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17
Have you ever tried to self-harm?Please answer yes or no. If yes, please provide dates and details.
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18
Have you ever had suicidal thoughts?Please answer yes or no. If yes, please provide dates and details.
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19
Have you ever experienced trauma or abuse?Please answer yes or no. If yes, please provide dates and details.
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20
Has alcohol ever been a serious problem for you?Please answer yes or no. If yes, please provide dates and details.
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21
Have you, or do you, take recreational drugs regularly?Please answer yes or no. If yes, please provide dates and details.
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22
Is there any additional information you would like us to know?
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