Assessment Form

The information you enter on this contact form will be sent to my email address. Please consider keeping sensitive information to a minimum for your data protection. I will ask you for more detail when we complete your assessment together. This form will save us time in the assessment and allow us to focus on creating a treatment plan.

The first two letters of your first name and last name (e.g. RaLa)

Payment

Self-funding

Bupa

Aviva

For Bupa & Aviva clients only:

Your Pre-authorisation code and excess amount

Details of any access needs (e.g. limited mobility, dyslexia)

Home address

GP Surgery

Have you had therapy before?

If so please include the approximate year(s), how many sessions and whether it was positive or not.

Feelings about therapy

What are your hopes and concerns regarding therapy?

The problem

Please describe the problem(s) you are facing in one or two sentences.

How have you been trying to cope with the problem(s)?

E.g. exercise, talking to people, alcohol, distracting myself.

Focus areas for therapy

What would you like to focus on? It could be a difficult relationship, adjusting to change, anger or finding purpose, for example.

Goals for therapy

What would like to change as a result of therapy? E.g. 1) Talk more openly with my partner; 2) Improve my sleep; 3) Feel less tearful

Assessment Form

rachel lackey counselling & therapy

Action