DAVID CHONG, MSW, BSW, RSW, RCC Registered Clinical Counsellor Registered Social Worker http://www.davidchongcounselling.ca Please fill out as much as you can CLIENT INFORMATION Name (Last ) (First ) Date of Birth D /M /Y ( ) Gender Male /Female Address Telephone Cell Home Work Email Address Care Card No. Third Party Plan Yes/No Insurance Company Emergency Contact Name Relationship Phone Referred by MARITAL / FAMILY BACKGROUND Marital Status Partner s Name Married/Divorced/Common-law/Single/Separated/Widowed/Unknown (English) ( ) Date of Birth Length of Partnership Previous Marriages/Partnership Date of Marriage Length of Partnership Reason for Separation Children Name Age Date of Birth Client lives with : Page 1
MEDICAL HISTORY Family Doctor Phone Date of last Doctor Visit Medical Condition(s) : Fax Date of last Physical Exam Medications : Previous hospitalization : Previous Counselling (Counsellor /Therapist /Psychologist /Psychiatrist ) Name of Counsellor(s) Length of Therapy Start Date End Date What did your counsellor do that was helpful?? What did your counsellor do that was not helpful?? What did you like about the counsellor s style?? What did you not like about the counsellor s style?? Page 2
FAMILY HISTORY Father Name Age Occupation Any Psychiatric problems (Diagnosis/Symptoms) Mother Sibling(s) Please complete these questions in as much detail as possible THERAPEUTIC GOALS Presenting Problem : When does it start?? When did it get worse?? Page 3
CURRENT FUNCTIONING Work Task : Occupation What do you do for work/school? How do you feel about work/school? Why?? Do you have any work/school related difficulties?? What would you change about work/school?? Describe your relationship with : Authority Peers Subordinates Self : How do you feel about yourself as a person?? Generally, how adequately do you feel you are functioning in your life right now?? Spirituality : What role does your religion play in your life?? Do you have a sense of belonging to a wider community/world/universe?? Page 4
Love/Intimacy Task : Describe your current intimate relationship. Describe any difficulties in the relationship. What would you change about your relationship? Social Task : How often do you see your friends?? Describe your social life. Describe intimacy with your best friends. How do friendships generally end?? What would you change about your social activities? Leisure 睱 : What do you do to have fun and relax?? Page 5
Limits of Confidentiality Personal information gathered in the course of counselling will be used in accordance with the purposes outlined in the paragraph above and will not be disclosed except as follows: v If a client threatens bodily harm to self or others v If there is an indication of child abuse v Counsellors under subpoena are bound by law to disclose information obtained during the course of counselling. v In order to provide better service, I may discuss your sessions with other professional counsellors also bound by confidentiality Cancellation Policy I ask that you cancel any appointment as soon as you are aware that it will not be needed so that the space can be filled by another client. If you give 24 hours notice of cancellation there will be no fee charged. If you give less than 24 hours notice a fee of $60 will be charged at my discretion. Missed appointments will be charged $60, also at my discretion. The service provided is a person centred talk therapy, which can bring deeper insight and awareness, better ways of understanding and coping with problems, as well as improved relationships. You should know, however, that counselling sometimes requires that you be willing to examine difficult topics or times in your life, to experience stronger than usual emotions, and to try out new and different behaviours. As a client, my options include discontinuing therapy and making complaint to the BCACC if I cannot resolve concerns with my counsellor directly. I have read and understand all of the above. I consent to receive counselling services from David Chong: Signature Signature of Counsellor Please print name Date Page 6