Questionnaire

Name:

Email:

Part 1 of 3: What would you like help with?

Outline the issue(s) for which you are seeking a consultation:

What do you hope therapy will do in relation to the concerns you have described above?

Have you tried anything else to improve matters?

Are any professionals involved in helping you with the issue(s) or have done in the past?

Have you suffered any trauma, important change, or loss?

Are you currently, or have in the past, harmed yourself or someone else in some way?

Do you have any current or previous physical health issues or any psychological diagnoses?

Or do you have mobility or other issues you'd like me to be aware of for your comfort?

If yes for either of the two questions above, please give details including any regular medication/treatment:

Please enter the name and address of your GP.

GP contact:

I give consent for my GP to be contacted

If applicable, please describe your employment status with details of responsibilities, hours of work:

Please describe who lives with you at home and their relationship to you:

How happy are you with your home circumstances?

How happy are you with where you live?

What are your hopes for the future?

Client questionnaire