Assessment Form The form has been successfully submitted. Thank you!Assessment FormThis form is used as part of the therapy assessment process. Fields marked with a * are required.CodeAre you an Adult or Young Person?*Adult (over 18)Child/ Young Person (under 18)What is your date of birth?*Who is your main family/ carer contact? (use mother, father etc. rather than using a name)*Do you attend school or college and if so what is your year group?*What is your work or occupation (if applicable)?What is your relationship status?Could you provide details of any children, dependents or caring responsibilties you have?What is your ethnicity/ cultural identity?Do you have a faith or religious beliefs?Are you adopted or do you have any adoption related issues?*YesNoCould you provide details? (adoption)What is your physical and emotional health like?Do you have any physical issues or disabilities?*YesNoCould you provide details? (physical issues or disabilities)If you have any other physical or learning disability, special needs or sensory impairment could you provide details?Have you been assessed elsewhere because of your difficulties?*YesNoCould you provide details? (assessed)Do you have any diagnosed mental health conditions?*YesNoCould you provide details? (mental health)Could you provide details of any prescription/ non-prescription medication you take?If you have used counselling, psychotherapy or psychiatric support before, when and what were the outcomes?Could you provide details of any alcohol or drug use?Are any other agencies or professionals involved in your care?*YesNoCould you provide details? (agency)Could you provide details of any previous significant illness, accidents or operations?Could you provide details of any past difficulties, for example family deaths or losses?If there is any family history of mental health issues could you provide details?Did you seek counselling or did someone else suggest this service?How did you hear about this service?GP DetailsName of GPGP Practice Name*GP Practice AddressGP Practice Phone NumberAre there any particular areas you would like help with?Do you have an particular goals or hopes for the outcome of the therapy?I give consent to the details provided on this form to be safely stored. For more detail see information sheet Your Data and Rights. Submit
