Adult Counselling Application Please enable JavaScript in your browser to complete this form.DateHow did you hear about my counselling services?What brings you to see me?NameFirstLastAgeBirthdayPreferred GenderWhat are your strengths:Medications:Education Level:Please choose belowLess then High SchoolHigh School DiplomaApprenticeshipDiploma/CertificateBachelor's DegreeMaster's DegreeDoctor/DoctoratOccupation:Relationship Status:Relationship History of Past Marriages/Divorce:Has your family lost a baby/child before birth? When?Have members of the family had any illnesses?Any deaths/losses that your family has experienced?What was your relationship with your parents like when young?How did you keep safe from any conflict when you were young?Do you have siblings? If so, what are their names and ages?Are you in contact with your siblings?Has you experienced an acute trauma?Has you experienced long term physical, emotional or sexual abuse?What hobbies/leisure activities do you have?Do you have close friends/colleagues?What do you do when things get challenging?Do you have regrets?Emergency Contact PersonFirstLastPhone Number:Relation to youSubmit
