Information for counselling clients - Couples
 All information is treated in the strictest confidence and used for administrative and monitoring purposes only.  
Sign in to Google to save your progress. Learn more
Email *
Full name *
Full Name of partner *
Date of birth *
MM
/
DD
/
YYYY
House number & Postcode *
Best telephone number *
Email address *
Occupation? *
Name, address and contact number of GP *
Are you receiving psychiatric services, professional counselling or psychotherapy elsewhere? *
Are you taking any medication? (Antidepressants or others) IF yes, what? *
Do you have any health concerns? *
How are your sleeping habits? *
Are you physically fit? Healthy eating habits, exercise regularly? *
Do you regularly use alcohol? *
If you answered yes or sometimes how often? *
Do you regularly use drugs? *
If you answered yes, how often? *
If you answered yes to alcohol or drugs, what do you use? *
Have you had any suicidal thoughts recently? *
Have you had them in the past? *
Whos is in your support network now? Are you in a romantic relationship? *
Have you ever experienced Domestic Abuse with partners or family members? *
Required
Have you had any losses/bereavement/accidents/significant events that has impacted you? *
Do you have any external agencies supporting you? If so who? *
Do you have any children? Any Child Protection Issues? *
Who would you prefer to see: *
Availability?
Would you prefer *
What do you consider to be your relationships strengths? *
What do you like most about yourself and your partner? *
What are your effective coping strategies that you have learned? *
What are your goals for therapy? *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of The Wellbeing Therapy Hut. Report Abuse
Google Forms