Counselling Initial Assessment Form
Counselling Initial Assessment Form
Please fill out this form to help us better understand your needs.
Date
Name
Date of Birth
Phone Number
Reason(s) for Seeking Counseling
Select all that apply:
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Stress/Anxiety
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Depression
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Relationship Issues
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Work-Related Challenges
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Grief/Loss
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Current Challenges
Select all that apply:
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Sleep Difficulties
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Loss of Interest in Activities
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Changes in Appetite
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Difficulty Concentrating
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Increased Irritability
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Goals for Counseling
Briefly describe what you hope to achieve:
Have you attended counseling before?
Additional Information
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