The Counselling Intake Form Template UK is provided in multiple formats including PDF, Word, and Google Docs, featuring customizable and printable versions for your convenience.
Counselling Intake Form Template UK Editable – PrintableSample
Counseling Intake Form Template UK 1. Client Information 2. Emergency Contact Information 3. Referral Source 4. Reason for Seeking Counseling 5. Mental Health History 6. Medical History 7. Family History 8. Current Support System 9. Goals for Counseling 10. Additional Information 11. Declaration and Consent
PDF
WORD
Examples
[Full Name]
[Date of Birth]
[Address]
[Phone Number]
[Email Address]
[Emergency Contact Name]
[Emergency Contact Phone Number]
[Relationship to Emergency Contact]
[Detailed explanation of the issues or concerns that brought the client to seek counselling services. This may include emotional, psychological, or situational factors.]
[Description of the client’s current life situation, including any relevant relationships, work circumstances, or other situational factors affecting mental health.]
[List any relevant medical history, including previous mental health diagnoses, treatments received, medications prescribed, and any ongoing health issues.]
[Information about the mental health history of close family members, including any known mental health issues or significant life events affecting the family.]
[Outline the client’s goals for therapy, including what they hope to achieve, such as improved coping strategies, resolution of specific issues, or personal growth.]
[The client acknowledges and agrees to the terms and conditions of counselling services, including confidentiality policies and the right to discontinue treatment at any time.]
[Signature of the Client]
[Name of the Client]
[Full Name]
[Date of Birth]
[Current Address]
[Primary Phone Number]
[Alternate Phone Number]
[Email Address]
[How did you hear about our services? (e.g., friend, doctor, online search)]
[Detailed description of current issues, symptoms, feelings, and thoughts that prompted the client to seek counselling.]
[Include significant life events, previous counselling experiences, and any relevant psychosocial factors that may impact treatment.]
[Details of any current medications, psychiatric history, and physical health concerns that the therapist should be aware of.]
[Information about the client’s social supports, including family, friends, and community resources that may provide assistance during treatment.]
[Outline what the client hopes to achieve through therapy and any preferences they have regarding the counselling process.]
[The client consents to treatment and acknowledges understanding of confidentiality policies, limitations of confidentiality, and the process for ending therapy.]
[Signature of the Client]
[Name of the Client]
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