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Client Assessment Form
Name
*
Address
*
Date of birth
*
Telephone number (home)
*
Telephone number (mobile)
*
Email address
*
GP name
*
GP address
*
GP telephone
*
Occupation
*
Marital status
*
Married
Single
Divorced
Widowed
Cohabiting
Civil Union
Dependant children
*
0
1
2
3
4
5 or more
Physical / mental health
(including relevant history)
Are you currently on any medication?
*
Yes
No
Please detail any medication
(including any side effects)
How many units of alcohol do you consume a week?
*
What is a Unit?
Are you a smoker?
*
Yes
No
Do you use recreational drugs?
*
Yes
No
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
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