Confidential Pre-Assessment Form

We would be grateful if you would take some time to complete this form, to give us an idea of your current situation in relation to your mental / emotional well-being.  If you need any help completing any parts of the form, please do not hesitate to contact us.

We are committed to protecting your privacy and keeping the information you provide confidential. Your information will not be used for any other purpose and is managed according to the General Data Protection Regulation (GDPR) and the Data Protection Act 2018. You can find more information regarding our privacy policy page.

Date of Birth
Initials
CULTURAL & FAMILY BACKGROUND
Origins
Do you have contact with your family?
How would you describe your relationship with the members of your immediate family?
SEXUAL ORIENTATION AND GENDER IDENTITY
Is there anything relating to your coming out or coming to terms with your sexual orientation and/or gender identity which you would like us to know about?
CURRENT SIGNIFICANT OTHERS & OTHER SUPPORT SYSTEMS / NETWORKS
On a scale of 0 – 4 (0 = not at all, 1 = occasionally, 2 = sometimes, 3 = often, 4 = mostly) Can you gain support or turn to:
Family
Friends/Partner
Community/Clubs/Religious Groups
Work Colleagues
MENTAL WELLBEING
How would you describe your current mental health?
Have you previously engaged in mental health services?
If yes, please give details about the services and duration etc:
Have you ever had a mental health diagnosis?
If yes, please give details about the diagnosis:
Do you take any prescribed medication for mental health issues?
If yes, please specify name of prescribed medication, dosage and how long you have been taking it.
Do you take any non-prescribed medication?
If yes, please specify name of non-prescribe medication, dosage and how long you have been taking it.
Have you ever self-harmed or had suicidal thoughts / attempted suicide?
If yes, please give details:
SUBSTANCE USE
Drugs & alcohol, prescription and non-prescription, other
Do you have any concerns about your use?
What would you say are the underlying issues, cues, triggers etc.?
Did drugs/alcohol play a role in your coming out? If so, please describe it.
Risks from using, incl. sexual health concerns, particularly HIV, Hep C?
SUBSTANCE USE PATTERN
Typical patterns and context of present use if applicable
Please describe your age, substance, any comments (e.g. How much, estimated cost, when where, who with/sharing?)
PREVIOUS HISTORY OF TREATMENT FOR SUBSTANCE USE
(e.g. self-detox, abstinence, controlled usage, scripting, detox, rehab, prison, other, what happened, ethos of treatment)
Please describe Date, Type of Treatment, Comments, Funder
PREVIOUS EXPERIENCE OF PSYCHOLOGICAL INTERVENTIONS (counselling; therapy; psychiatry)
Please describe Date, Who with, For How Long, Reason for Ending, Usefulness
If your previous experience of counselling/therapy was not useful, what do you think will make this experience different?
Please describe up to 4 major issues or difficulties that you hope counselling will help you with.
How would you describe your physical and sexual health?
Do you have any additional needs that you would like us to know about?
Please give details regarding employment, training, qualifications:
Please give details regarding interests and hobbies:
Please give name, address, telephone details of your GP:

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