Free Counselling Initial Assessment Form Template

Counselling Initial Assessment Form

Please fill out this form to help us better understand your needs.

Date

    Name

      Date of Birth

        Email

          Phone Number

            Reason(s) for Seeking Counseling

            Select all that apply:

              • Stress/Anxiety

              • Depression

              • Relationship Issues

              • Work-Related Challenges

              • Grief/Loss

              Current Challenges

              Select all that apply:

                • Sleep Difficulties

                • Loss of Interest in Activities

                • Changes in Appetite

                • Difficulty Concentrating

                • Increased Irritability

                Goals for Counseling

                Briefly describe what you hope to achieve:

                  Have you attended counseling before?

                  Additional Information

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