Counselling Assessment Form

Please complete this form in full noting any instruction in the form. Before completing this form please read assessment instructions. If you experience any problems with this form please contact any of the following;

Technical Issues – Tonii Bell – tbell.arcus@gmail.com
Clinical/Admin Issues – Sarah Henderson – Sarahhen.arcus@gmail.com
Safeguarding Issues – COMPLETE CSI – This will alert the entire safeguarding team

Client Name *

Assessors Name *

Date *

Hours *

Minutes *

Client DOB - YOU MUST ENTER THIS

Client Phone Number

Client Email Address - YOU MUST ASK CLIENT SPECIFICALLY FOR THIS - *

Clients preferred pronouns

Client Home Address

Name and Address of Clients GP Surgery

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?

Do we need to complete a CSI for this client?

Yes - Complete a CSINo - Carry on with Assessment

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

Clients preference on practitioners genderClient 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]OTHER/Client has no gender preference for Therapist

Suitable for CounsellingYesNo

Clinical Approach - [COUNSELLING ONLY - NOT WAM] Explore with client whether they have has previous therapy and if they have a preference for clinical approach. - Also considering the presenting complaints would one style be best? Indicate belowPresenting Complaint Suitable for CBTPresenting Complaint Suitable for Integrative therapistPresenting Complaint Suitable for Person Centered TherapistPresenting Complaint can work with any - Client has no preference

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

Means Test Outcome - Explore with client how many hours they work and if they are on a means tested benefit, Clients will default to standard rate unless requirements for reduced rate are met. Assessor may fee remit at their own discretion, if there is demonstrable financial hardship.

Standard £25 - works 10 or more hoursReduced £25 - works less than 10 hours or is actively seeking work / long term sickness / claiming means tested benefitsFee remitted (discretion of assessor)No payment necessary as client is paid for by 3rd party or existing agreement e.g. PHD/Family Help referral

Payment - If payment is required send SumUp link for immediate payment - If payment is Deferred/ Not required also indicate this

Payment Information - Select which applies:

Client has been sent a payment link for immediate payment - they have paid today and been advised that an automated email receipt will be emailed to themClient was sent a payment link for payment later - They have been advised that they should pay within 7 days or they may be discharged - Automated email will be sent to clientNo payment is needed as client is fee remitted.Payment is not required due to existing agreement with PHD/Family help etc.Payment is being made by Social Prescribers - Payment link created and to be emailed to referring SP (assessor to complete using details on referral form)

Notes

Arcus is Linked to the Social Prescriber Service [DARLINGTON ONLY] - If this applies, please inform the client we can refer them on for help with any of the following criteria, if those criteria apply. The client only needs to meet one of these to qualify for this service - 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

Assessment Complete - Suitable for Social Prescribers - Consent ObtainedYes - Client will receive an automated email (Clinical Lead to Action)No - N/A

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.

Assessment Complete - Fee RemittedYes - Client Informed they will receive an automated emailNo - N/A

Assessment Complete Payment MadeYes - Client advised that they will receive a receipt for thisNo - Payment link is pending Clinical Lead to monitor

Assessment Complete Payment PendingYes - Client has been sent an automated email advising of payment terms and conditionsNo / N/A / Payment already recieved

Assessment Complete 3rd Party PaymentYes - Payment link to be emailed to referring party - Assessor to actionNo - N/A

Assessment DNA Rebooked Into Assessors ClinicYes - Assessor to use Reschedule link in Calendar to rebook client into their next available clinicN/A Client Attended Assessment

DNA x 2 Discharge - Is this the clients second booking for assessment?Yes - Client will receive an automated email discharging them - Clinical Lead to ActionNo - Client Attended

Client Opted Out During AssessmentYes - Client will receive automated emailNo - Client is progressing as planned

Was the client able to engage in the assessment process, demonstrating the necessary capacity and psychological watershed for our services/Gillick Competency is in place or N/AYes - they meet the above conditionNo - They do not meet the above condition - Automated email will be sent to client

Date of Submission *

Time of Submission *

Hours

Minutes