Pre-counselling form

First Name *

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

Country *

Email Address *

Phone no *

BACKGROUND

What do you enjoy doing or are you passionate about?

What is the problem or issue that you need counselling for?

What have you done about it in the past?

How do you know you have this problem?

How is it a problem for you now specifically?

How much time does it take?

How long have you had this problem? Was there a time it wasn’t there?

Tell me the first time that you remember this problem started

Tell me about your childhood in relation to this problem

Tell me about your father, mother, and siblings in relation to this problem

What do you want from this counselling/therapy?