Counselling Assessment Form
Please complete this form to assist with safeguarding and to assist with your counselling work.  Your records are used and kept for the duration of the counselling work only and not shared unless you tell me you will harm yourself or someone else. After work has ended they will be deleted. This is not an emergency service.  If you need to talk urgently please call the Samaritans on 116123 or go to your closest A & E.  Thanks for your time. Karen
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Karen Bell Counselling https://karenbellcounselling.com/

email:  karenbellcounselling@gmail.com
Name and date of birth *
Date you are completing this form. *
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Phone and email *
Doctor name and contact information *
Medication and reason for taking  *
Please indicate how often and how much you use alcohol or other substances for coping. *
Please indicate with a number from 1-5 how supported you feel in your life.

1 is low and 5 is high
 *
Required
Please indicate how you feel about yourself currently from 1-5, where 1 is lowest and 5 is highest.
 *
About thoughts and feelings of suicide.  This is not if you did attempt to harm yourself:
Clear selection
Please give me a brief expectation of what you would like to gain from counselling/ *
Submit
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