Clinical Assessment

There are no right or wrong answers, please share whatever comes to mind.
If you feel strongly about not sharing certain information at this time, please omit it.
It will best for you to complete the assessment at a time when you are unlikely to be disturbed.

 

Identification

Name:

E-mail:

Date of birth (dd/mm/yyyy):

What is your marital status?:

If you currently have a partner, what is their name?:

Sex:  female  male

Race/ethnic identity?:

Do you have any children? --- Yes No  If so, what are their names and ages?

What is your current employment?  How long have you been there?: years

Do you live alone or with someone?:

Do you have any religious affiliation?:

How did you find this site?


Presenting Problems

What problems and concerns bring you to counseling?:


Describe what motivated you to seek help at this time rather than some time in the past or future?:


How long have you been feeling this way? (for each feeling or problem)?:


What happened at the time you began feeling this way?:


When have you felt like this in the past and what happened?:


Since you have been feeling this way do you feel worse or better now?:



Describe Your Past Medical/Counselling History: