Pre-Counselling Questionnaire

This form is designed to provide me with some information prior to your first appointment with me. This way, we will not spend valuable counselling time completing paperwork.

Please fill out the following as completely as possible. This information is confidential. If you have concerns about the relevance of any information and wish to leave it out, please feel free to do so.

Today's Date:

Your Complete Name:

Date of Birth:

Address:

Street Number/Name

City:

Postal Code:

Preferred Telephone:

May I leave a message:

Yes

No

Detailed Message

Alternate Telephone:

May I leave a message:

Yes

No

Detailed Message

Email

May I use this email address to contact you?

Yes

No

Detailed Message

Have you ever had counselling before? Yes No

If you have had counselling before, when?

Have you ever been hospitalized for a mental health issue? Yes No

If you have been hospitalized, when?

Current Occupation:

Are you presently off work?

Yes

No

If yes, since when?

Relationship status:

Never married

Common law

Married

Separated

Divorced

Widowed

Spouse/partner’s first name:

Years in relationship

Children (names, ages):

Please describe any significant current or past medical problems:

Are you concerned about your alcohol or drug use?

Yes

No

Are others concerned about your alcohol or drug use?

Yes

No

Have you experienced negative consequences as a result of your use?

Yes

No

If yes, please describe?

During the last 12 months how often and how much did you use: (see table below to determine Standard Drink (SD) equivalencies.)

Alcohol Never Less than once per month 1-3 times per month 1-2 times per week 3 times per week or more

Cannabis Never Less than once per month 1-3 times per month 1-2 times per week 3 times per week or more

Other drugs Never Less than once per month 1-3 times per month 1-2 times per week 3 times per week or more

Prescription Never Less than once per month 1-3 times per month 1-2 times per week 3 times per week or more

Tobacco Never Less than once per month 1-3 times per month 1-2 times per week 3 times per week or more

Caffeine Never Less than once per month 1-3 times per month 1-2 times per week 3 times per week or more

Spirits (40%)	Beer 5%	Wine (12%)
43 ml (1 ½ oz) = 1 SD 375 ml (13 oz) = 9 SD 750 ml (26 oz) = 18 SD	1 small can (341 ml) = 1 SD 1 king can (750 ml) = 2 SD 1 boss (950 ml) = 3 SD	1 glass (5 oz/142 ml) = 1 SD ½ litre = 3.5 SD Bottle (750 ml) = 5 SD

Normal Range: Women: 10 drinks per week with 2 per day maximum Men: 15 drinks per week with 3 per day maximum

In your own words, what is the problem that you wish to address in counselling?

Is there anything else you think I should know in order to fully understand your situation?

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