Date Of Birth
Spiritual, religious views:
Who Else Lives With You?
Approximate alcohol intake per week in units:
Do you smoke? If so, how much?:
Any other drug use?
Hobbies and interests:
Brief outline (reason for being here):
What is the cause?
Why do you want to make a change?
When did this start?
What makes it better?
What makes it worse?
On a scale of 0 to 10 with zero being I’d rather die than carry on and 10 being I’m great as I am. Please read below, how intensely you feel this problem is affecting you?
Using the same scale of 0 to 10 Please rate below, your overall satisfaction with your life, as a whole.
If you didn’t have this problem, how would your life be different?
What has stopped you from changing, up until now?
Have you recently consulted your GP? If yes please supply a brief outline.
If the problem is weight or eating related what is your current weight?
What is Your Height?
Have you recently gained or lost weight in an unexplained way? Tick box for yes.
Do you frequently have pains in your heart and or chest area? Tick Box for yes.
Do you often feel faint or have spells of severe dizziness? Tick Box for yes.
Has your doctor ever told you that you have high blood pressure? Tick for yes.
Has your doctor ever told you that you have or might have a bone or joint problem? Tick for yes.
Do you know of any physical reason not mentioned that may be important?
Please list any current physical health problems:
Please list any medical or surgical procedures you have undergone in the last 2 years:?
Please list all medication currently taken:
Have you ever suffered a head injury that resulted in loss of consciousness or brain trauma? Tick for yes.
Have you ever had any kind of fit? Tick for yes.
Have you received inpatient psychiatric treatment, and if so: what, where and for how long?
What do you think stops you from changing?
What will be different once we have changed?
How will this change affect you, your family and friends?
What have been some of your best accomplishments to date? I.e. the ones that you value?
Imagine a time in the future after you have made those changes... Now... From this point in the future, look back at the time when you did have that problem... Compare the old problem with how you are in the future. What are some of the particular outstanding differences you can now experience in and of yourself?
Again... In the future after you have made these changes, start looking ahead further into the future... What are some of the new opportunities... Experiences... And... Possibilities... Opening up for you, what are particularly attractive or exciting to you?
What are your expectations for our first session together?
Do you have any other relevant information or comments to share? (Feedback about this form can be included)