Client Goals and Self Assessment

This form is designed to capture some of your personal circumstances and thoughts as we begin the process of counselling. We hope that it will help the initial sessions to be as effective as possible. You do not have to fill it in if you don’t want to.

Should you have any questions or require further details please contact Anne Lindley-French on anne@gardengate.org.uk or 07961190749.

Please click here to complete and submit an online version of this form. Right mouse click from your PC and select the Print option if you would like to print a hard copy.

Garden Gate Therapy – Client Goals and Self Assessment

Name:
Date:
Date of Birth:
Employment:
GP Name & Address:

Why have you chosen to come to counselling at this time?

What changes would you like to see?

Relationships

Status: Single / Married /Cohabiting / Separated / Divorced / Widowed / Other (please specify):

Length of Time Together:

Details of Any Previous Relationships:

Details of Any Children:

Age: Name: Male/Female: Living With: In Contact With: Adopted/Fostered:
1
2
3
4
5
6

1 Do you, or have you had, any physical medical conditions? Yes/No Please provide details and dates if you have answered yes:

2 Do you, or have you had, any mental health conditions? Yes/No Please provide details and dates if you have answered yes:

3 If you answered yes to Q1 or Q2 will this affect our sessions? Yes/No Please explain how if you answered yes:

4 Are you currently taking any medication? Yes/No Please provide details and dates if you have answered yes:

5 Have you had any previous counselling? Yes/No Please provide details and dates if you have answered yes:

6 Have you ever tried to self-harm? Yes/No Please provide details and dates if you have answered yes:

7 Have you ever had suicidal thoughts? Yes/No Please provide details and dates if you have answered yes:

8 Have you ever experienced trauma or abuse? Yes/No Please provide details and dates if you have answered yes:

9 Has alcohol ever been a serious problem for you? Yes/No Please provide details and dates if you have answered yes:

10 Have you or do you take recreational drugs regularly? Yes/No Please provide details and dates if you have answered yes:

Is there any additional information you would like us to know?

Click here to complete an online version of this form. You can download a digital copy or right mouse click from your PC and select the Print option to print a hard copy.