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Personal Counselling Questionnaire 

Private and Confidential

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Full Names: *
Address

Your preferred Contact Method & Details

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Contact Details for Preferred contact method? 
Preferred Day of session booking? (Availability Permitting)
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Preferred time of session booking? (Availability Permitting)
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Date of Birth:
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Occupation:
Next of KIn Name and Contact Details:
Spouse/Partner Name 
Relationship Condition:
Have either your spouse/partner or yourself been in a marriage/committed relationship before: 
Your Previous Relationship: 
Spouse/Partner Previous Relationship: 

Dependants: 

Own Dependants:

Spouse or Partner Dependants:
Do you or your family have any physical/mental health conditions: 
If yes, provide detail:
What achievement/s are you most proud of:
Do you have interests/hobbies:
Do you have close friends and regularly spend time together: 
Have you experienced a traumatic event or been traumatised: 
If yes please provide detail:
Have you been abused?
Do you have any spiritual/faith affiliations or beliefs? 
How did you hear about Lemon Aid Life: 

I hereby give consent to release the information recorded above to my Lemon Aid Life Coach for his/her private and confidential records or at my request for a clinician appointed and authorised for my medical care. 

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