Self Assessment Form

CONFIDENTIAL ASSESSMENT FORM

    How did you hear about Harman House Counselling Centre? Please circle as appropriate:

    Medical History including any current medication.

    Name,Telephone number and Address of GP

    Please give the name and telephone number of someone we could contact in case of an emergency:

    Have you attended counselling here before?

    We have a Stairlift should you need it, unfortunately anybody weighing more than 18 stone is not able to use Stairlift.

    Please tick below when you are regularly available for appointments (please tick as many spaces as you can):

     

    MORNING (10 AM - 12 NOON)

    AFTERNOON (12 - 5 PM)

    EVENING (6 - 8 PM)

    MONDAY

    TUESDAY

    WEDNESDAY

    THURSDAY

    FRIDAY

    SATURDAY