Counselling Questionnaire

Prefix

First Name

Middle Name

Last Name

Email Address

Phone *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

What type of Counselling are you looking for ? *

What is your Gender ? *

Age *

How do you Identify Yourself? *

What is your relationship status? *

Do you consider yourself religious? *

Which religion do you identify with? *

Have you ever been in a couselling before? *

How would you rate your current physical health? *

How would you rate your current eating habits? *

Are you currently experiencing overwhelming sadness, grief, anger or depression? *

How often do you use alcohol or drugs? *

When was the last time you thought about suicide? *

Are you currently taking any medication? *

How would you rate your current financial status? *

In your own words, please describe what you'd like to speak with a counsellor about: *

Are you in crisis? (Crisis refers to thoughts of self-harm, harming others, child welfare concerns, recent trauma, recent death of a loved one etc.) *

Appointment Date *

VaCCT

Counselling Questionnaire

What led you to consider counselling now? *

What are your expectations from your counsellor ? A counsellor who... *

What would you like to meet with a counsellor about? *