NAME
*
First Name
Last Name
EMAIL
*
DATE OF BIRTH / AGE
*
ETHNIC ORIGIN
How would you identify yourself? If you’d rather not say, please put ‘RNS’
SEXUAL ORIENTATION
How do you identify yourself (i.e straight/heterosexual / gay/lesbian / bisexual or other orientation)? If you’d rather not say, please put ‘RNS’
PREFERRED PRONOUNS
i.e. he / him she / her they / them other
EMPLOYMENT STATUS
OCCUPATION
HEALTH
Please indicate any health issues
FURTHER HEALTH INFORMATION
If you have ticked any of the boxes in the previous health section please give details or use this space to outline any other health issues past or present which have had an impact on your life / relationship plus list any medication you're currently taking.
My physical home environment feels comfortable
My work environment feels comfortable and positive
I exercise regularly (3+ times a week)
I eat healthily most of the time
I keep well hydrated every day
I have good gut health
I feel my hormones are well balanced
I sleep well most, or all, of the time
I get plenty of access to daylight each day
I am able to recognise, articulate and manage my own emotions
I am able to recognise and understand the emotions of others
I am able to calm myself down when stressed or anxious
I feel I have a good support network
HOLISTIC REVIEW - FURTHER DETAILS
ADDICTIVE BEHAVIOURS
Are drugs or alcohol or other addictive behaviours such as gambling, use of pornography etc. causing difficulties in your life (or your partner’s life, if applicable)?
DOMESTIC ABUSE
Thinking about your current relationship (if applicable) - is there currently, or have there ever been,
issues around domestic violence in this relationship? (this could be physical, verbal, financial, emotional or sexually abusive behaviour)
PREVIOUS COUNSELLING / THERAPY
Have you had counselling or therapy in the past?
CURRENT COUNSELLING / THERAPY
Are you having any counselling or therapy currently?
If you've ticked yes to either question please outline dates, duration, type of therapy and effectiveness (where known)
CURRENT RELATIONSHIP STATUS (if applicable)
*If you ticked 'other' in the previous section please give details
LENGTH OF CURRENT RELATIONSHIP (if applicable)
Please outline the timeline of your relationship ie dates when you met / started living together / got married / entered a civil partnership etc.
CHILDREN
Please indicated whether you / your partner (if applicable) have children and give their ages and gender
FOCUS OF COUNSELLING
Briefly outline the areas you'd like to focus on in our sessions
PREVIOUS SIGNIFICANT COUPLE RELATIONSHIPS (if applicable)
Please use this space share anything you'd like me to know about any previous relationships
ANY OTHER NOTES
Please use this area to share anything else you'd like me to know that hasn't been covered in this form
