Client Self Report

Please provide the following information and bring the form to your first session. 
Please note: the information provided here is confidential.
First Name:                                                                Phone number:
Last Name:                                                                Best times to call:
Gender:                                                                      Is it ok to leave a message?
Date of birth:                                                             Email:
Address:                                                                      Is it ok to send you an email?

What days and times are you available for sessions?  I will try to accommodate your schedule as much as I can.
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday
____________________________________________________________________________________________________________________________

What would you like to discuss in Counselling?
What are your main concerns?        How long has the problem been going on?        

Ranking:  0 = Not at all distressing        to         5 = Extremely distressing

1.    Partner/ Lack of
2.    Separation/ Divorce/ Thoughts of
3.    Communication/ Conflict with partner/ Others
4.    Family issues
5.    Parent/ child
6.    Issues with children/ grandchildren
7.    Eldercare
8.    Friends/ social contacts/ support
9.    Work-related
10.   Co-worker/ colleague
11.    Supervisor
12.    Career
13.    Health/ Illness
14.    Sexual health
15.    Weight/ self
16.    Developmental transitions (Physical health changes)
17.    Personal growth
18.    Spiritual religious practices
19.    Financial
20.    Legal
21.    Emotional health
22.    Trauma
23.    Grief/ loss
24.    Stress
25.    Anger
26.    Depression
27.    Suicidal
28.    Anxiety/ panic attacks/ fear
29.    Compulsive behaviour
30.    Internet/ video games/ self/ other
31.    Alcohol- self/other
32.    Drug - self/other
33.    Gambling - self/other
34.    Porn viewing. - self/other
35.    Violence - Family  (a) physical    (b) verbal/ emotional
36.    Violence - Non-family    (a) physical    (b) verbal/ emotional
37.    Sexual abuse



Please print this page and fill in your rating prior to coming to a counselling session.
This way we will be able to talk about issues more quickly rather than filling in paper during session.

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