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.

Street Number/Name

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

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