©Routledge/Taylor & Francis 2014

Counselling and Psychotherapy Assessment Form

Name / Phil Thomas
DOB / 28th Feb 1957
Gender / Male
Occupation / Lecturer
Marital Status / Married
Children
(including ages) / Two children: one daughter aged 21years and one son aged 15years
Address
(including postcode) / 6 Fictional Street, Invented Road,
Pretend Town, P26 1LI
Telephone / 093657493864
Can we contact you on these numbers and may we leave a message if you are not available? / Please contact on my mobile number and you can leave a voicemail message
Name and Address
of Current GP / Dr Who, What Surgery, Nowhere, LG86 1IT
Are you currently experiencing any physical or psychological illnesses? If so, please indicate these problems. / No serious illnesses, but have been
feeling stressed and anxious lately
Are you currently taking any prescribed medication? If so, please indicate this medication. / No
Are you currently undergoing any other counselling, psychotherapy, or psychological treatment? If so, please indicate this treatment. / No
Have you previously received counselling or psychotherapy? If so, please indicate the type of therapy, when it was received, and how long it lasted. / I had person-centred counselling
for ten sessions in 1989
Do you drink alcohol or use any recreational drugs? If so, please indicate average usage. / No
Do you now or have you previously attempted to hurt yourself or had suicidal thoughts? / No
Have you recently experienced any significant life events, such as bereavements, losses, accidents, changes, stress, etc.? / I have had some recent signs of
stress and anxiety
How would you describe your current health? Please include any problems relating to sleeping, activity, appetite, depression, anxiety, grief, phobias, etc. / Good health, other than stress
and anxiety
What are the main issues that have brought you to therapy? / My tendency to procrastinate.
I think that this is resulting
in my anxiety and stress
What would you like to gain out of your time in therapy? / I would like to get a better understandingof myself, and my patterns of behaviourso that I can stop procrastinating andstop feeling anxious.

Thank you for completing this assessment

Please return this form to the

RiversongCounselling and Psychotherapy Practice

To be completed by the assessing counsellor in the practice:

31/01/12

Date of Assessment ______

Person-Centred Therapy

Recommended Therapy ______

Elaine Ward

Recommended Therapist ______

Riversong Counselling and Psychotherapy Practice, Invented Place, Nowhere, L42 3DR