Counselling History-Taking Form HTMLBasic InformationFull Name *Age *Date Of Birth *0 / 10Gender *MaleFemaleOtherMarital Status *SingleMarriedDivorcedWidowedOccupation *0 / 20Education Level *High SchoolGraduatePostgraduateOtherContact Number *Email Address *Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweHTMLPresenting Concerns & GoalsWhat brings you to counselling? *AnxietyDepressionStressRelationship IssuesFamily ConflictsWork-related stressGrief/LossLow self-esteemAnger issuesTrauma/PTSDAddictionsOther(Check all that apply)CheckboxOption 1Option 2If Other, write here *0 / 100How long have you been experiencing these issues? *Less than a monthA few monthsMore than a yearHave you received counselling before? *YesNoIf yes, when? *Was it helpful? *YesNoWhat are your main goals for counselling? *0 / 150HTMLPersonal & Family HistoryHow would you describe your childhood? *HappyAverageDifficultAny significant childhood events that impacted you? *Parental divorceLoss of a loved oneAbuse/NeglectBullyingOtherIf other, write here *HTMLFamily BackgroundParental Relationship Status *MarriedDivorcedSeparatedDeceasedYour relationship with parents *CloseDistantConflictualDo any family members have a history of mental health issues? *YesNoDo you have supportive relationships?YesNoSomewhatCurrent living situation *AloneWith familyWith roommatesOtherIf Other, write here *0 / 150HTMLMental & Emotional HealthDo you experience any of the following? *Persistent sadnessMood swingsFrequent cryingPanic attacksIntrusive thoughtsExcessive worryingDifficulty concentratingAnger outburstsSocial withdrawalSuicidal thoughtsOther(Check all that apply)If other, write here *Have you ever been diagnosed with a mental health condition? *YesNoIf yes, specify *Have you ever had thoughts of self-harm or suicide? *YesYes, in the pastYes, recentlyHow do you currently cope with stress or emotional difficulties? *ExerciseMeditationTalking to someoneAvoidanceSubstance useOtherIf other, write here *HTMLPhysical Health & LifestyleOverall Physical Health *GoodAveragePoorDo you have any medical conditions? *NoYesYes, specify here *Do you take any medications? *How many hours of sleep do you get per night? *Less than 44-66-8More than 8Do you engage in regular physical activity? *YesNoDo you use substances (alcohol, tobacco, drugs)? *NoOccasionallyRegularlyHTMLRelationships & Social LifeHow would you describe your relationships? *FulfillingStrainedNeutralDo you feel comfortable expressing emotions in relationships? *YesNoSometimesHave you experienced any of the following in relationships? *Emotional abusePhysical abuseBetrayal/infidelityLack of trustLack of communicationNone of the aboveDo you have a strong social support system? *YesNoSomewhatHTMLWork & Career SatisfactionAre you satisfied with your job/career? *YesNoSomewhatDo you experience work-related stress? *Yes, frequentlySometimesNoHow would you describe your work-life balance? *GoodNeeds ImprovementPoorHTMLSpirituality & Personal GrowthDo you consider yourself spiritual or religious? *YesNoUnsureDo you practice meditation or mindfulness? *YesNoSometimesAre you actively working on self-improvement or personal growth? *YesNoSomewhatHTMLCounseling Expectations & PreferencesWhat type of counselling do you prefer? *IndividualCouplesFamilyGroupWhat do you expect from counselling? *Emotional supportSolutions & guidanceCoping strategiesPersonal growthImproved relationshipsAre you open to assignments (journaling, mindfulness, etc.)? *YesNoMaybePreferred counselling approach (if any preference)? *Talk therapyCognitive Behavioral Therapy (CBT)Mindfulness-basedPsychoanalysisNo preferenceAdditional NotesSend Message
