Traffic light: ……………………………………..
Creation date: ………………………………
Client Contact number: ……………………………………………..
Client gender: ………………………………
Client name:
D.O.B:
Primary alleged perpetrator:
Primary incident:
CSA,
domestic abuse,
Stalking/harassment,
no incident,
not able to obtain,
rape,
sexual exploitation,
third party incident, emotional abuse, Physical abuse.
Incident impact/ coping mechanisms:
Agoraphobia,
alcohol misuse,
eating disorder,
fear,
mental health,
mistrust,
anger/aggression,
flashbacks,
anxiety,
intrusive thoughts,
nightmares, OCD,
overdose,
confusion,
depression,
loss of work/income,
panic attacks,
School problems, sleep problems, suicidal thoughts, suicide attempts,
drug misuse,
low self-esteem,
PTSD,
self-harm,
work problems.
Other (please list)
Any issues that could prevent you attending counselling sessions?
Marital status:
Civil partner, cohabiting, divorced, in relationship, married, not appropriate, prefer not to say, separated,
single, widow, widower.
Sexuality:
Bisexual,
celibate,
Prefer not to say,
gay man,
lesbian,
heterosexual,
not appropriate,
other,
under 16, unsure.
Disabilities:
Blind, visual impairment, deaf, hearing impairment, learning difficulties, long term illness/ health condition,
Mental health, mobility (physical), speech impairment, none, not obtained, prefer not to say
Employment status:
Benefits:
Someone Cares is a not for profit organisation registered under the Industrial and Provident Society act 1965-78 F.S.A Reg No:29399R
BACP No: 136018 DML2014. © Copyright. For the use of SomeOne Cares Only.
Nationality:
Ethnicity:
Asian,
Asian British,
Black,
Black British,
Chinese,
White,
other ethnic group,
prefer not to say.
Immigration status:
Primary language:
Language difficulty:
None,
some difficulty,
issues,
request for interpreter,
not yet obtained
Religion:
Family/ friends support:
Mixed,
supportive,
unsupportive,
not told.
Accommodation: (i.e. home owner local authority etc.)
Living with:
Client address:
Emergency contact:
Name:
Contact numbers:
Client email:
Contact number:
G.P surgery /address:
Current medications/ health issues?
Tel:
Any pending/ ongoing court/ police involvement?
Other agency involvement?(i.e. social services etc)
Referral:
Have you had counselling before?
Self (via) telephone, email, website, Facebook, Twitter
No
Other.
Yes (give details)
Agency (agency details)
Someone Cares is a not for profit organisation registered under the Industrial and Provident Society act 1965-78 F.S.A Reg No:29399R
BACP No: 136018 DML2014. © Copyright. For the use of SomeOne Cares Only.
Client availability:
Monday
Tuesday
Wednesday
Female counsellor:
Thursday
Friday
Saturday
Male Counsellor:
Either:
Overview of incident/s
Client aims for counselling?
Questions about you and your impressions of your current position:
No
Sometimes
Yes
Do you feel safe?
1
2
3
4
5
Do you feel listened to?
1
2
3
4
5
Do you feel you have enough support?
1
2
3
4
5
Do you feel isolated/lonely?
1
2
3
4
5
Do you feel empowered to make choices in life?
1
2
3
4
5
Your feelings about yourself:
Bad
Neutral
Good
How do you rate your opinion of self?
1
2
3
4
5
How is your overall mood?
1
2
3
4
5
Allocated counsellor:
Venue:
Assessment conducted by: ………………………………………………………..
Start date:
Signed: …………………………………………………………
Someone Cares is a not for profit organisation registered under the Industrial and Provident Society act 1965-78 F.S.A Reg No:29399R
BACP No: 136018 DML2014. © Copyright. For the use of SomeOne Cares Only.
Reason for closure/disengagement
Attempts to contact client
Additional info
Someone Cares is a not for profit organisation registered under the Industrial and Provident Society act 1965-78 F.S.A Reg No:29399R
BACP No: 136018 DML2014. © Copyright. For the use of SomeOne Cares Only.
Someone Cares is a not for profit organisation registered under the Industrial and Provident Society act 1965-78 F.S.A Reg No:29399R
BACP No: 136018 DML2014. © Copyright. For the use of SomeOne Cares Only.