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Please read this form before completing it. We request this is completed 24 hours before your session, which allows us to prepare for your session however If you feel uncomfortable filling out this form – please fill out this alternative form instead: click here.

Therapists making notes

Employee counselling form

MM slash DD slash YYYY
Your address
G.P. Surgery name
G.P. Address
G.P. Phone number
Company Name
Your issues. Please describe the nature of your difficulties, how long you have had them, how you think they began and how they affect your life at present.
In what ways do you hope that treatment such as, if appropriate, counselling or therapy could help you?
Have you ever sought help for emotional or psychological difficulties? If so, please give details: helped by GP, counselling or psychotherapy, referred to a psychiatrist, hospitalised, etc.?
Has any other family member had help for psychological difficulties (please give details as far as you know them).
Trigger warning. Have you ever made a suicide attempt/suicidal thoughts or self-harm? If you've answered yes, please could you give some details about when this occurred?
Are you on any medication at present for emotional/psychological difficulties, if so, please list these?
Is there any concern about your drinking or issues with non prescribed/prescribed drugs?
Have you ever had issues with eating? If so, please give details below. Do you have any difficulties with your body? The way you feel about it and the way you think it looks?
Are you experiencing problems in relationships?
How do you cope with situations?
How easy do you find it to recognise your own thoughts?
Is there anything you’ve tried which has worked for you?
Mother: Please describe your relationship.
Father: Please describe your relationship.
Siblings: Please describe your relationship.
What was the general atmosphere like at home, including how your parents got on with each other?
Were there any important changes, for example, moves or any other significant events, during childhood? Including any separations from the family or parental divorce. Please give approximate ages and details.
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