Client Information Sheet

Name *

Email Address *

Phone *

Date of Birth *

Street Address *

City

State/Province

ZIP / Postal Code

GP Details [name, practice, number]: *

Emergency Contact Details [name and number of next of kin or emergency contact]: *

Alcohol Intake per week: *

Do you smoke or vape: *

Recreational Drug Use: *

Do you consider yourself to have a disability: *

Have you had previous counselling, if so, where at, and how did you find this? *

Do you have any physical or mental health problems that may affect counselling? *

Do you take any regular medication that may influence your counselling or that we may need to know about? *

Are there any other agencies or organisations involved with your ongoing care that we may need to know about? *

Briefly what are your presenting complaints [what do they want to talk about in therapy – brief outline only] *

Any other information that we need to know: *