Request edit access
LeadingEdge WellBeing Counselling Questionnaire
Please fill out the following
Name *
Name of parent/guardian (if under 18 years) *
Date of birth *
MM
/
DD
/
YYYY
Gender *
Email *
Address *
Marital status *
Please list any children/gender/age *
Have you previously received any type of mental health service before? *
Previous therapist/ practitioner
Are you currently taking any prescribed medication? *
GENERAL HEALTH AND MENTAL HEALTH INFORMATION
How would you rate your current physical health? *
Poor
Very good
How would you rate your current sleeping habits? *
Poor
Very good
How many times a week do you exercise?
What types of exercise do you participate in? *
Are you currently experiencing any overwhelming sadness, grief or depression?
Clear selection
If yes, how long for?
Are you currently experiencing anxiety, panic attacks? *
If yes, when did this begin happening?
Do you drink alcohol more than once a week? *
How often do you partake in recreational drug use? *
Are you currently in a romantic relationship? *
If yes, for how long *
How would you rate your relationship? *
Poor
Very good
What significant life changes (if any) or stressful events have you experienced recently? *
FAMILY HEALTH HISTORY
In this section please identify family history of the following:
Please tick *
Required
Additional Information
Are you currently employed? *
If yes, what is your current employment/occupation? *
On the scale, how stressful is your job? *
Not Stressful
Highly Stressful
What would you like to accomplish out of your time in therapy? *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms