Client Self Report

Copy this page and paste onto a Word document.
Add your information onto it and email to  to make an appointment and before the first session. 

What would you like to discuss in Counselling? What are your main concerns?  

How long has the problem been going on? 


Please provide the following information as well. 
Note: the information provided here I will keep confidential.  

First Name:                                                                Phone number:
Last Name:                                                                Best times to call:
Gender:                                                                      Is it okay to leave a message?
Date of birth:                                                             Email:
Address:                                                                     Is it okay to send you an email?

State the best days and times that you available for sessions? 
I will try to accommodate your schedule.
Monday       Tuesday       Wednesday       Thursday       Friday