Online Counselling Intake

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Client Details

Full Name

Preferred Name

Date of Birth

Age

Pronouns (optional)

Telephone Number (Required)

Email Address (Required)

Gender Identity

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Preferred Method of ContactTelephoneEmailText MessageWhatsApp

May we leave voicemail messages?YesNo

Emergency Contact & GP Information

Emergency Contact

Emergency Contact Name

Relationship to You

Telephone Number

Alternative Telephone Number

Emergency Contact PermissionYesNo

GP Information

GP Practice Name

GP Name

Street Address

City

State/Province

ZIP / Postal code

Country

Practice Telephone Number

GP Contact ConsentYesNo

Assessment Information

What brings you to counselling?

How long have you been experiencing these concerns?

Goals for counselling

Current SymptomsAnxietyPanic attacksLow moodDepressionStressSleep difficultiesIrritabilityDifficulty concentratingRelationship difficultiesGrief or bereavementTrauma-related symptomsObsessive thoughtsCompulsive behavioursLow self-esteemAngerSocial withdrawalEating concernsSubstance misuse concernsSelf-harm thoughtsSuicidal thoughtsOther

Health & Risk Assessment

Previous Counselling?YesNo

If Yes

Approximate Date

Type of Therapy

Was it Helpful?

Mental Health Diagnosis?YesNo

Diagnosis Details

Hospital Admission?YesNo

Admission Details (If Yes)

Current Medical Conditions?YesNo

Medical Conditions Details(If Yes)

Current Medications

Allergies?YesNo

Allergy Details( if Yes)

Alcohol and Substance Use

Do you currently consume alcohol?YesNo

If yes, approximately how many units per week?

Do you currently use recreational drugs?YesNo

If yes, please provide details:

Do you have concerns regarding alcohol or substance use?YesNo

Risk Assessment

Self Harm Thoughts?YesNo

Suicidal Thoughts?YesNo

Plans Made?YesNo

Do you feel safe?YesNo

Further Information

Family and Social Background

Who lives with you?

Relationship status:SingleMarriedCivil PartnershipIn a RelationshipSeparatedDivorcedWidowed

Do you have children?YESNO

Occupation:

Are there any significant family, social, cultural, or religious factors you would like your counsellor to be aware of?

PHQ-9 Depression Questionnaire

Over the last two weeks, how often have you been bothered by the following?Not at allSeveral daysMore than half the daysNearly every day

1. Little interest or pleasure in doing thingsNot at allSeveral daysMore than half the daysNearly every day

2. Feeling down, depressed, or hopelessNot at allSeveral daysMore than half the daysNearly every day

3. Trouble falling or staying asleep, or sleeping too muchNot at allSeveral daysMore than half the daysNearly every day

4. Feeling tired or having little energyNot at allSeveral daysMore than half the daysNearly every day

5. Poor appetite or overeatingNot at allSeveral daysMore than half the daysNearly every day

6. Feeling bad about yourselfNot at allSeveral daysMore than half the daysNearly every day

7. Trouble concentratingNot at allSeveral daysMore than half the daysNearly every day

8. Moving or speaking slowly, or being unusually restlessNot at allSeveral daysMore than half the daysNearly every day

9. Thoughts that you would be better off dead or of hurting yourselfNot at allSeveral daysMore than half the daysNearly every day

If you checked any problems, how difficult have these made daily life?Not difficultSomewhat difficultVery difficultExtremely difficult

GAD-7 Anxiety Questionnaire

Over the last two weeks, how often have you been bothered by the following?

1. Feeling nervous, anxious, or on edgeNot at allSeveral daysMore than half the daysNearly every day

2. Not being able to stop or control worryingNot at allSeveral daysMore than half the daysNearly every day

3. Worrying too much about different thingsNot at allSeveral daysMore than half the daysNearly every day

4. Trouble relaxingNot at allSeveral daysMore than half the daysNearly every day

5. Being so restless that it's hard to sit stillNot at allSeveral daysMore than half the daysNearly every day

6. Becoming easily annoyed or irritableNot at allSeveral daysMore than half the daysNearly every day

7. Feeling afraid as though something awful might happenNot at allSeveral daysMore than half the daysNearly every day

How difficult have these problems made daily life?Not difficultSomewhat difficultVery difficultExtremely difficult

Counselling Agreement

I understand that: ** Counselling is a collaborative process and outcomes cannot be guaranteed. * I may withdraw from counselling at any time. * I am responsible for attending appointments or providing notice of cancellation in accordance with the practice policy. * Information shared in counselling is generally confidential. * Confidentiality may be broken where required by law or where there is serious concern regarding the safety of myself or others. I have had the opportunity to ask questions regarding the counselling procesI confirm that I understand and agree.

Privacy Notice and UK GDPR Consent

I understand that: ** My personal information will be processed in accordance with UK GDPR and the Data Protection Act 2018. * My information will be securely stored. * I may request access to my records. * I may request correction of inaccurate information. * Information will be retained in accordance with the practice's retention policy. * I have received or been directed to the practice privacy notice.I consent to the collection and processing of my information for the purposes of providing counselling services.

Communication Consent

Please indicate how you consent to being contacted.

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