Client Details Form

NEW CLIENT DETAILS FORM

Welcome to Logan Counselling Services. We look forward to providing you with caring and affordable counselling services. Please take a few minutes to fill out this form. The information will help us to better understand your situation as well as potential solutions in helping you get your life back on track. Please note - the information is confidential, for our use only, and will not be released to anyone without your written permission.

Personal Information

Client first name *

Client surname *

Date of birth *

Age *

Gender *

FemaleMale

Street address *

Suburb *

State

Postcode

Religious Affiliation (if any)

Home phone

Is it okay to leave a message on home phone?

YesNo

Work phone

Is it okay to leave a message on work phone?

YesNo

Mobile phone *

Is it okay to leave a message on mobile?

YesNo

Email Address *

May we email you?

YesNo

Medicare Number

Medicare Expiry

DVA Number

NDIS Number

Emergency Contact Information

Emergency contact *

Emergency contact's phone *

Emergency contact’s relationship to you *

Work Information

Occupation

Employer

Length of employment

Social / Family Information

Which best describes you? Choose all that apply.

If you are currently in a relationship, for how long?

On a scale of 1 to 10 (with 10 being best), how would you rate your satisfaction with your current relationship?

Do you have children? If so, please provide names and ages.

If you have listed children, with whom do they live?

Do you have any pets in the home? If so, what type?

List any other individuals living in your home (other than you and any children listed above):

Medical and Mental Health History / Information

Are you currently being treated by a doctor for any medical conditions? If so, please describe:

Are you currently taking prescription, over-the-counter or herbal medication?

YesNo

If Yes, Provide medication name/dose

Have you ever seen a Psychiatrist or other mental health provider?

YesNo

If Yes, when?

What was the focus of treatment?

Was it helpful?

YesNo

Counselling Concerns

What are the issues for which you are currently seeking assistance? Please be as specific as possible. *

What have you previously tried in order to resolve these issues (e.g. religious counselling, talking with family/friends)? Has anything been helpful? *

What are some of your coping strategies? *

What do you consider to be your strengths? *

Counselling Goals

Goals are very important in counselling. They provide us with a focus and direction that will help us to help you. Please list the goal(s) that you hope to address and achieve in counselling. Please be as specific as possible.

Goal 1 *

Goal 2

Goal 3

Goal 4

Risk Assessment

Is there any family history of mental illness or substance abuse? If so, please list relationship & diagnosis:

Please list family, friends, support groups and community groups which are helpful to you:

List any personal history of emotional, physical, and/or sexual abuse:

Has a family member or close friend ever committed suicide?

YesNo

If Yes, who?

Have you been having any thoughts of harming yourself or others?

YesNoSelfOther(s)

Have you ever been involved in any significant legal actions, currently or in the past (e.g.: lawsuit, probation, parole)? If so, please state who and under what circumstances:

Alcohol / Substance Use Survey

Do you use marijuana or other “street drugs”? (Remember, this information is confidential)

NoYes

If Yes, what type/quantity/frequency of use?

Check here if you prefer not to answer in writing and choose to discuss this privately with the therapist

Referral Source

How did you learn about Logan Counselling Services?

Consent

Thank you for taking the time to fill out this form.

In signing below I acknowledge that the information I have provided is true and correct to the best of my knowledge at the date signed.

Further, I acknowledge that I have been provided with a Logan Counselling Services brochure detailing consent and rights/responsibilities of undertaking counselling, (downlod your copy of the brochure here) I also acknowledge that it is my responsibility to read the aforementioned document and if I am unsure of any of the information I will ask for clarification from Logan Counselling Services staff.

Client name

Date

Signature

Draw signature|Type signatureClear

Save and Complete Later