Client Information Form

In the event of an emergency and we cannot reach you directly, or we need to reach someone close to you, whom should we call?

Name *

First

Last

Phone Number *

Relationship *

Education/Training/Employment

Education Completed *

Any Other Training *

Current Occupation *

Name of Employment Company *

Employer Address *

Family Background

How would you describe your relationship with your parents? *

Healthy Conflictual

How would you describe your childhood? *

Happy Unhappy

Are you closer to one parent than the other? *

Yes No

If Yes, who? *

Mother Father

Please provide details *

Do you have any siblings? *

Yes No

Please provide details, e.g. brothers/sisters, how many: *

Please complete the following section if you will be engaging in martial/pre-marital counselling or counselling regarding your marriage or relationship.

Name of Partner/Spouse *

First

Last

Address of Spouse (if different to yours) *

Contact Number *

Occupation of Spouse *

Age *

Any Children? *

Yes No

How many? *

Religion *

If yes, are they a product of your current relationship? *

Yes No

How long have you been married? *

How old were you when you got married? *

How old was your spouse when you got married? *

How long did you know your spouse before marriage? *

How long did you and your partner date for prior to marriage? *

Were you engaged? *

Yes No

If yes, for how long? *

Have either of you ever filed for divorce? *

Yes No

If yes, Please provide details *

Were you or your spouse previously married? *

Yes No

If yes, please provide details including by what means did the marriage end e.g. death or divorce *

Is your spouse willing to come to counselling? *

Yes No Uncertain

Religious and Racial/Ethnic Identification

Current religious denomination/affiliation *

Which (if any) church do you/did you attend? *

How often do you attend church? *

Involvement *

None Some/Irregular Active

Do you believe in God? *

Yes No Uncertain

Do you pray to God? *

Yes No Uncertain

How important are spiritual concerns in your life? *

Ethnicity/national origin *

Race *

Your Medical Care

Who is your primary care giver (doctor/clinic)? *

Phone Number *

Address *

How would you rate your physical health *

Very Good Good Average Declining

Any major health concerns i.e. illness/injuries/disabilities (past or present) *

Are you presently taking any medication? *

Yes No

Please provide details if yes *

Have you experienced any significant trauma (physical or emotional) which you believe is still impacting you currently? *

May we contact your medical doctor so that we can coordinate your treatment if deemed necessary? *

Yes No

May we contact your former counsellor/therapist for additional information to assist us during our therapeutic if deemed necessary? *

Yes No

Personality Information

Have you ever felt like people were watching you? *

Yes No

Do people’s faces ever seem distorted? *

Yes No

Do colours seem too bright? *

Yes No

Are you able to judge distances? *

Yes No

Have you ever had hallucinations? *

Yes No

Are you afraid of being in a car? *

Yes No

Referral

Were you referred by someone or did you self-refer? *

Referred by someone Self-referred

What was the reason for their referral? *

Do you agree with the reason of their referral? *

Yes No Uncertain

Reason for Service

Please complete this section if you are a parent referring your child (under 18) to be seen by a counsellor

What is the issue you wish to address with a counsellor with your child? *

Has your child ever received any form of counselling or form of therapy for this issue before? *

Yes No

Please provide details if yes *

Have you tried anything else to address this issue? *

Yes No

Please provide details if yes *

How do you believe we can help you with this issue? *

Is there any other information that you wish to share that you believe will be helpful for your counsellor to know? *

Yes No

Please provide details if yes *

Please complete this section if you are seeking counselling for yourself

What is the issue you wish to address with a counsellor? *

Have you ever had any form of counselling or form of therapy for this issue before? *

Yes No

Please provide details if yes *

Have you tried anything else to address this issue? *

Yes No

Please provide details if yes: *

How do you believe we can help you with this issue? *

Is there any other information that you wish to share that you believe will be helpful for your counsellor to know? *

Yes No

Please provide details if yes: *

Client Information Form

Identification

Emergency Information

Education/Training/Employment

Family Background

Religious and Racial/Ethnic Identification

Your Medical Care

Your Medical Care

Personality Information

Referral

Reason for Service

We Would Love to Have You Visit Soon!

Telephone: (246) 429-5757
Mobile: (246) 232-4661
Fax: (246) 429-5759

Email: [email protected]

Hours: Monday - Friday| 8 - 4

Join Our Mailing List

Client Information Form

Identification

Emergency Information

Education/Training/Employment

Family Background

Religious and Racial/Ethnic Identification

Your Medical Care

Your Medical Care

Personality Information

Referral

Reason for Service

We Would Love to Have You Visit Soon!

Telephone: ​(246) 429-5757Mobile: (246) 232-4661Fax: (246) 429-5759

Email: [email protected]

Hours: ​Monday - Friday| 8 - 4

Join Our Mailing List

Telephone: (246) 429-5757
Mobile: (246) 232-4661
Fax: (246) 429-5759

Hours: Monday - Friday| 8 - 4