form - Anna Critisinelis

Client information form

Please enable JavaScript in your browser to complete this form.

Name

First

Last

Tel

D.O.B

Address

Please outline the issue(s) you would like to explore in therapy?

Where did you hear about my service?

Medication:

Working role:

Relationship status:

Alcohol use:

Other substance use:

Current sleep:

Current appetite:

Previous Counselling / Psychotherapy:

Have you recently or in the last 12 months had any dark thoughts or thoughts around suicide?

Any previous suicidal plans?

Any other risky behaviours?

around use: Address

Family history of mental health / illness?