Client Intake Form

Name (an alias may be used to maintain confidentiality)

First

Last

Private Email Address (This is a required field so we can contact you) *

1.0 Goals for Counselling: What goals, outcomes, problems or issues do you need help with? *

2.1 Goals for Living: What goals or outcomes do you want to achieve?

2.2 Goals for Living: What problems, issues, challenges or obstacles do you want to overcome?

3.0 What is this (problem or issue) preventing you from achieving?

4.1 What has this (problem or issue) cost you in the past, up until now?

4.2 What is this (problem or issue) costing you now, in the present?

4.3 Upside: Are there any benefits to you that come from having this (problem or issue)? List them here.

4.4 Downside: What symptoms, consequences, challenges or costs arise from this (problem or issue)?

5.1 When did this (problem or issue) first start?

5.2 Who else is involved with this (problem or issue)?

5.3 How are they involved with this (problem or issue), specifically?

5.4 What is the impact on yourself and others involved with this (problem or issue)?

5.5 Who, if anyone, is positively impacted by this (problem or issue)? How might they benefit from it?

5.6 Who, if anyone, is negatively impacted by this (problem or issue)? How might they suffer from it?

5.7 Would you say this (problem or issue) places limits on your day to day activities? How, specifically?

5.8 Would you say this (problem or issue) leads to believe things about yourself that may not be true?

5.9 Do you or anyone else, actively or passively contribute to maintaining this (problem or issue)? If so, How?

6.1 How long has this (problem or issue) been going on?

6.2 What efforts, if any, have you made in the past, to address this (problem or issue)?

6.3 How did that turn out for you, and others affected by this (problem or issue)?

6.4 What efforts, if any, are you making in the present, to address this (problem or issue)?

6.5 How is that turning out for you, and others affected by this (problem or issue)?

6.6 If this (problem or issue) is caused by a behaviour you could stop, have you tried to stop it before?

6.7 What happened when you tried to stop it?

6.8 If this (problem or issue) is caused by a behaviour you could stop now, are you trying to stop it?

6.9 What happened when you tried to stop it, most recently?

6.10 List any actions you have taken, or deliberately not taken, to stop this behaviour, if relevant.

6.11 Have any of these actions or inactions to date resulted in the problem or issue being reduced?

6.12 Which actions or inactions have led to the biggest reduction in the problem, if any?

6.13 What (do you believe) made those actions or inactions most effective?

6.14 What other support have you received to date regarding this (problem or issue)?

6.15 Does that support include professional help (i.e. previous counselling)? If so, please specify.

6.16 What was most effective about this support you received? List the 3 biggest benefits.

7.0 What kind of support are you looking for from this new counselling relationship? Please specify here.

7.1 Self Care: Do you have a self care plan in place to ensure your physical and psychological wellbeing?

11.1 Safety and Risk: Have you ever had any persistent thoughts about harming yourself or others?

11.2 Safety and Risk: Have you ever put a plan in place to end your life?

11.3 Have you ever attempted suicide? If Yes, how often and when?

11.4 Do you have a safety plan in place to address suicidal thoughts or impulses?

11.5 Who is your emergency contact to enact your safety plan?

11.6 Have you ever had a mental health emergency (i.e. have you ever been involuntarily hospitalised)?

11.7 Are you on any medication that affects you physically or mentally? Please specify.

Reminder: Please also complete an Informed Consent Form

You will need to complete an informed consent form prior to the commencement of therapy

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