Client Assessment Form | Warwick Counselling Services

If you are human, leave this field blank.

Name *

Address *

Date of birth *

Telephone number (home) *

Telephone number (mobile) *

Email address *

GP name *

GP address *

GP telephone *

Occupation *

Marital status *

Dependant children *

Physical / mental health

(including relevant history)

Are you currently on any medication? *

Yes

Please detail any medication

(including any side effects)

How many units of alcohol do you consume a week? *

Are you a smoker? *

Yes

Do you use recreational drugs? *

Yes

Any relevant family information?

Any relevant religious/cultural information?

What is your knowledge of counselling?

Please briefly describe the reason(s) for coming to counselling now

Details of any other relevant professional you are seeing now

Checkboxes *

Please confirm you have read our Privacy Policy