Counselling Assessment - LGBT+ Counselling, Support & Awareness

Date of Appointment(required)

Counsellor Name:(required)

Method of Session(required)

Attended Yes / No / Details / Comments – record here if DNA or CANC(required)

Client Date of Birth(required)

What gender counsellor would the client like to see? (required)

If not applicable above, please put details here, if this is not needed enter N/A (required)

Are there any changes to personal information since referral, if so, please document them here:(required)

GP Details [name, practice, number]:(required)

Emergency Contact Details [name and number of next of kin or emergency contact]:(required)

Alcohol Intake per week? (Inform client they can self-refer to NECA or via another local service or GP for this)(required)

Do you smoke, and would you like assistance with stopping? (Inform client they can self-refer to local smoking cessation via GP)(required)

Recreational Drug Use? (Inform client they can self-refer to NECA or via another local service or GP for this)(required)

Have you had previous counselling, if so, where at, and how did you find this?(required)

Do you have any physical or mental health problems that may affect counselling?(required)

Do you take any regular medication that may influence your counselling or that we may need to know about?(required)

Do you consider yourself to have a disability?(required)

Are there any other agencies or organisations involved with your ongoing care that we may need to know about?(required)

Briefly what are your presenting complaints [what do they want to talk about in therapy – brief outline only](required)

Any other information ?(required)

Feeling nervous, anxious or on edge =(required)

Not being able to stop or control worrying =(required)

Worrying too much about different things =(required)

Trouble relaxing =(required)

Being so restless that it is hard to sit still =(required)

Becoming easily annoyed or irritable =(required)

Feeling afraid as if something awful might happen =(required)

TOTAL FOR GAD [total of previous items max score of 21] =(required)

Little interest or pleasure in doing things=(required)

Feeling down, depressed, or hopeless=(required)

Trouble falling or staying asleep, or sleeping too much=(required)

Feeling tired or having little energy=(required)

Poor appetite or overeating=(required)

Feeling bad about yourself, or that you are a failure or have let yourself or your family down=(required)

Trouble concentrating on things, such as reading the newspaper or watching television=(required)

Moving or speaking so slowly that other people could have noticed? Or the opposite being really fidgety or restless =(required)

Thoughts that you would be better off dead or of hurting yourself in some way=(required)

TOTAL FOR PHQ [total of previous items max score of 27]=(required)

Detail here any risk and the action you have taken to mitigate it:(required)