SCS Pre-assessment Form

"*" indicates required fields

SCS Pre-assessment Form

Silverset Counselling Service
Southeast London & Online
Phone: 0784 762 0103 Email: info@silversetcounselling.com
Website: www.silversetcounselling.com
Sunninghill Rd, Lewisham, London, SE13 75S

Please fill in the required information.

"*" indicates required fields

1. Client's Name*

First Name Last Name

2. Phone*

3. Email*

Enter Email Confirm Email

4. RESIDENTIAL ADDRESS*

Street Address City Postal Code Country

5. Age*

Please enter a number greater than or equal to 0.

6. Gender*

7. Religion*

8. Ethnicity*

9. Sexuality

10. Martial Status

Civil/Partnership/Co-habiting

Divorced/Dissolved

Married

Separated/Widowed

Single

11. Cultural Backgrounds

Asian or Asian British

Caribbean/African/African decent/British

Mixed/Multiple ethnic groups/British

Caucasian/European/European decent/British

Other

Enter your answer

12. Occupation

13. Employment Status

Full-time employment

Part-time employment

Unemployed

Retired/Semi-retired

Self-employed

Other

Enter your answer

14. Where did you hear about SCS:

E.g. (Online search, friend, G.P., etc.)

REFERREL DETAILS:

15. Self-referred

Yes

16. Referring for

Please indicate the category for counselling.

Youth Individual Counselling (16-20 years)

Individual Counselling (21+)

Couples Therapy

Family Therapy

17. REFERRED BY:

Please Indicate Name of Referrer & Telephone no.

Name

Phone

Telephone

18. Name of Parent(s) / Guardian (if under 18):

Please Indicate Parent(s) / Guardian Name(s) & Telephone no.

Name

Phone

Telephone

Name

Phone

Name

Phone

19. Have you had any type of counselling in the past?*

Yes

How long was your previous counselling?

20. How did you find your past counselling session(s)?

PRESENTING PROBLEM(S):

21. Please choose one or more reason(s) for counselling therapy?*

Academic difficulties

Addiction

Anger

Anxiety

Bereavement / Loss

Depression

Disability issues

Domestic violence

Eating / Diet issues

Emotional issues or problems

Family difficulties

Family separation / Divorce

Fear / Panic attacks

Financial difficulties

Health (physical)

Identity issues (background, culture, faith, gender, humanity, religion, etc.)

Life-coping strategies

Loneliness / Isolation

Low moods

M/H issues (Anxiety disorders, BPD, PTSD, etc.)

Migration / Immigration (non-legal)

Negative thoughts (NAT's)

Physical abuse

Problematic friendships

Self-esteem / Self-worth

Self-harm

Sleeping difficulties

Stress / Fatigue

Trauma

Work difficulties

22. Other presenting Issues:

Please name any other issue(s) for counselling.

23. Why now for counselling?*

What made you decide to seek counselling at this time.

24. Counselling Goals:*

What issues / problems would you like to work on?

RELATIONSHIPS & SUPPORT SYSTEM

25. Relationships:*

Please name - (Parents, Partner, Siblings, etc.)

26. Friends & other social emotional support:

Who are the people who support you socially, emotionally, spiritually?

OTHER INFORMATION

27. Any other information:

Is there anything else, you think would be helpful for us to be aware of?

HEALTH / WELLBEING INFORMATION

28. How is your appetite?*

What's your diet like?

29. What is your sleep pattern like?*

How many hours of sleep, per night, do you gey in total?

30. Your general health?*

How is your current health generally?

31. Your GP details?*

Your GP's name or surgery:

32. GP / Surgery address:*

33. Your GP's contact number:*

34. How is yours or your family's mental health history?*

Please provide as much details as possible.

35. Has anyone received a psychiatric diagnosis?*

36. Psychiatric consultant / Therapists:*

RISK INFORMATION

37. Do you smoke?*

Yes

Sometimes

Please provide further details, how long & history.*

38. Do you drink alcohol?*

Yes

Sometimes

Please provide further details, how long & history.*

39. Drug use?*

State whether you use recreational drugs.

Yes

Sometimes

Please provide further details, how long & history.*

40. Suicidal thoughts?*

Have you had any suicidal thoughts recently?

Yes

Please provide further details, how long & history.*

41. Do you have any plans?*

Please discuss further with the accessor & your counsellor?

Yes

42. Do you have self harming tendencies?*

Please discuss further with the accessor & your counsellor?

Yes

Please provide further details, how long & history.*

43. Any other Areas?*

Are there any other issues or information that you would like to share? (E.g. safeguarding, abuse, criminal record, etc.)

Yes

Please State below:*

Please provide further details, how long & history.*

COUNSELLING PREFERENCE

44. What would you prefer?*

State your choice of counsellor

Any Counsellor

Counsellor of choice

State choice:

45. Please state your preference below:*

Counsellors are flexible and can work face-to-face or remotely.(LIS STUDENTS ONLY)

Face-to-face Counselling

Remote Counselling

Both Face-to-face and Remote Counselling

Phone Counselling

Your preferred medium for remote counselling*

Please choose one

ZOOM

SKYPE

FACETIME

TEAMS

GOOGLE CHAT

PHONE

OTHER

Please state any other medium:*

Your availability for face-to-face sessions.*

At LIS (LONDON) - Wed 8:00 to 20:00; Thurs 13:00 to 20:00; Fri 8:00 to 12:00 - PLEASE STATE EXACT TIMES

Your availability for remote sessions.*

(Mon to Fri) 8:00 am to 8:00 pm - PLEASE STATE EXACT TIMES

DISCLAIMER: All information taken from prospective clients, for this referral compiles with the GDPR regulations (2020).
The counselling process: Upon receipt of your assessment form, you will be allocated a counsellor, who will contact you initially, about your availability to start your first therapy session. During your first appt, you and your counsellor will get acquainted and review your assessment from together. where you cam discuss about your issues further. This is the beginning of your 8-wk counselling journey. If after 8 weeks you require additional sessions, please discuss this with your counsellor.

ALL ASSESSMENT FORMS SHOULD BE SENT VIA EGRESS SECURE MAIL, THROUGH GOOGLE DOCS OR DIRECTLY THROUGH OUR WEBSITE.
Thank you for your referral. We will endeavour to respond to your email as quickly as possible. However, please be aware that there may be a slight delay of up to 24 - 72 hours in responding to your referral, as we only have intermittent access to our emails.

FOR EMERGENCY CONTACT:-Samaritans, 116 123 {if you urgently need to talk to someone} - NHS Urhent Help for Mental Health: https://www.nhs.uk/using-the-nhs/nhs-services/mental-health-services/where-to-get-urgent-help-for-mental-health/ - Call your local A & E {if you urgently need to take action}.

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Agreed Fee {PAID BY LIS}

Cancellation Policy to be discussed at the assessment / initial appt. with assigned counsellor.

46. Name of Assessing Counsellor (INTERNAL ADMIN)

47. Please print name or insert electronic signature

Client's Signature

Accepted file types: jpg, png, pdf, Max. file size: 2 MB.

Name

48. Today's Date*

DD slash MM slash YYYY