Counselling Assessment Form

Client Name *

Assessors Name *

Date *

Hours *

Minutes *

Client DOB *

Client Phone Number *

Client Email Address

Clients preferred pronouns

Client Home Address

Who is your GP/What Surgery do you use?

Do you have an emergency contact, someone that we could call in an emergency NB we do not routinely feedback to this person, this is just a safety measure if you become ill or we have a serious concern for your wellbeing.

Do you have any physical health conditions?

Do you have any mental heath conditions? eg Schizophrenia, Personality Disorder, etc [anxiety or depression are not included here]

What medication [if any] do you take?

Are there currently any other individuals involved in your ongoing care?

Social Services / Social WorkerEarly Help / Early Intervention TeamCrisis TeamGP Aligned Mental Health TeamSocial Prescribing TeamOther Counsellor / Counselling ServicePrivate Psychiatrist / Psychologist

Other / Details of the Above

Does the client use any of the following? and do they want any assistance with stopping [if so signpost them to their GP]

AlcoholRecreational Drug UseCigarettes / Tobacco / Vaping

Details of the Above

Presenting Complaints - discuss with client and summarise here, what they want to bring to the service, what do they want to explore / work on, what do they want from the service?

GAD 7 Assessment

In the last two weeks [14 days], how often has the client been bothered by the following items. Score each item:

Feeling nervous anxious or on edge? *

Not being able to stop or control worrying? *

Worrying too much about different things? *

Trouble relaxing? *

Being so restless that it is hard to sit still? *

Becoming easily annoyed or irritable? *

Feeling afraid as if something awful might happen? *

Total Scores for GAD 7 Assessment

Scores from the GAD 7 assessment represent: *

PHQ 9 Assessment

In the last two weeks [14 days], how often has the client been bothered by the following items. Score each item:

Little interest or pleasure in doing things? *

Feeling down, depressed, or hopeless? *

Trouble falling or staying asleep, or sleeping too much? *

Feeling tired or having little energy? *

Poor appetite or overeating? *

Feeling bad about yourself, or that you are a failure or have let yourself or your family down? *

Trouble concentrating on things, such as reading the newspaper or watching television? *

Moving or speaking so slowly that other people could have noticed? Or the opposite being really fidgety or restless? *

Thoughts that you would be better off dead or of hurting yourself in some way? *

Total Scores for PHQ 9 Assessment

Scores from the PHQ 9 assessment represent: *

Risk Assessment

Is the client currently experiencing any of the following?

Suicide IdeationSelf Harm IdeationMedical EmergencySafeguarding / Abuse / Neglect

Details of Above

Current Risk Level

Zero risk - no risk of suicide or self harmLow Risk - thoughts only of suicide or self harmMedium Risk - thoughts and active plan of suicide or self harmHigh Risk - thoughts, active plan and intent of suicide or self harm

Action taken by Assessor to Mitigate Risk

Do we need to complete a CSI for this client?

Yes - Complete a CSINo - Carry on with Assessment

Client Preferences - Discuss & Explore The Following and Indicate Accordingly

Suitable only for Qualified CounsellorSuitable for Student Counsellor and / or Qualified CounselliorPresenting Complaint Suitable for CBTPresenting Complaint Suitable for Integrative therapistPresenting Complaint Suitable for Person Centered TherapistClient has indicated that they would prefer a male therapist [we can not guarantee this but will take it into account when allocating]Client has indicated that they would prefer a female therapist [we can not guarantee this but will take it into account when allocating]Client has no gender preference for Therapist

Means Test - This is to ascertain what fee level we will charge the client:

Means Test Outcome - Discuss with client how many hours they work and indicate as follows:

Standard £25 - works 10 or more hoursReduced £20 - works less than 10 hours or is actively seeking work / long term sickness / claiming means tested benefitsFee remitted (discretion of assessor)

Payment - We now need to take payment from the client, this can be done using STRIPE [immediate over the phone] or sum-up where we send them a link to pay later. Inform client that all payments MUST be made within 7 days of assessment.

Payment Information - Select which applies:

Client has made payment today over the phoneClient was sent a payment link and advised that they should pay within 7 days or they may be dischargedNo payment is needed as client is fee remitted.Payment is being made by a 3rd party

Notes

Arcus is Linked to the Social Prescriber Service [DARLINGTON ONLY] - explore the following with client and indicate as necessary:

Client is or may be experiencing social isolationClient is or may be experiencing an issue with their housingClient has an ongoing need or goal, that if met will ameliorate their presenting complaintClient has a hobby or interest, which if encourage or met, would ameliorate their presenting complaintClient has financial difficulty or hardshipClient is actively seeking work

Assessor has explored the possibility of linking the client with to the social prescriber service:Client HAS given their consent for a referral to Social Prescriber Service by sending a copy of their assessment to them.Client HAS NOT given their consent for a referral to Social Prescriber Service by sending a copy of their assessment to them.

SP EMAIL ADDRESS - INCLUDE THIS FOR ALL REFERRALS DESRCIBED ABOVE FOR SOCIAL PRESCRIBING TEAM - COPY AND PASTE - livingwell.darlington@nhs.net

Date of Submission *

Time of Submission *

Hours

Minutes