Client Initials *

Start Date

Age *

Gender *

Occupation *

Please list any past or present serious medical complaints *

Have you been involved in any serious accidents or incidents that your practitioner would need to know about? *

Is there any known family history of psychiatrics/poor mental health *

Please list any past or present medication related to any psychological issues *

Do you drink alcohol? If so how much per week? *

Do you drink tea/coffee/or other caffeinated drinks?, if so how many per day? *

Do you smoke? If so how much per day? *

Have you ever taken non prescribed drugs? If so what and when? *

Have you been for therapy anywhere else before? If so how many times and where? *

Marital Status *

Do you have any children? If so, what are there ages? *

Are there any special services involved with your children? *

Explain your living arrangements *

Are you involved with any other services such as social work, addiction team, crisis team? *

Have you ever had any criminal offences? If so what and when? *

Do you have a community psychiatric nurse? If so please give details *

Do you have a psychiatrist? If so please provide details. *

Have you ever received a diagnosis for your mental health? If so please provide details *

Are you in any form of crisis at the moment where you want to harm yourself or anybody else? *

Do you or have you ever self harmed? *

Have you ever attempted suicide? *

Are you currently in danger of being harmed by anyone else? *

Do you feel safe at home? *

Do you have any additional needs I can support? *

Have you ever been admitted to hospital for your psychological health? *

What are your helpful coping strategies *

What are your unhelpful coping strategies *

Who do you have for support in your life? *

What issues would you like to deal with when working with your coach? *

What are your goals? *