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Pre-assessment Questionnaire

Please fill out this questionnaire ahead of your free 20 minutes consultation call.

If you have not yet booked a consultation, I will contact you via the email address provided in this questionnaire to arrange an appointment with you.

Preferred name*

Last name

Initials*

Email*

Address *

I will only ever use this information in the case of an emergencies where this information might be needed.

Date of birth*

Gender identity:

Is your gender identity different from the gender assigned at birth?*

Yes

No

Prefer not to say

Sexual orientation:

Ethnicity and nationality:*

In a scale of 1 - 5, with 1 being lowest (worst) and 5 being the highest (best), how would you rate your mental health in the past two weeks?*

1 (lowest)

2

3 (neutral)

4

5 (highest)

Briefly describe your scorer above.*

What is your presenting issue? (please give as much detail as you can)*

Family and cultural background: (e.g. origins, number of siblings, parents, etc.)*

Do you still have contact with family?*

Yes

No

How would you describe your relationship with your family?*

Do you have any mental health or physical health diagnoses?*

Yes

No

Under assessment

Unsure

If yes, what conditions have you been diagnosed with?

Are you on any medication?*

Yes

No

If yes, what medications are you currently taking?*

Have you had therapy or counselling before? (please provide details)

What are your goals and expectations of therapy? (try to list 3 or 4 issues that you need to discuss in sessions)*

Do you have a history of, or currently a victim of domestic abuse?*

Yes

No

Unsure

Prefer not to say

What is your availability? (select all that apply)*

Monday morning

Monday afternoon

Tuesday morning

Tuesday afternoon

Wednesday morning

Wednesday afternoon

Thursday morning

Thursday afternoon

Friday morning

Friday afternoon

Other availability.

Please tell me any availability that is not listed above for example evenings, as I have some evening slots.

What are your interests and hobbies?

Please provide GP details*

I will only use your GP details when required to do so if I believe you are at harm to yourself or others.

I declare that the info I’ve provided is accurate and complete.

To find out how Therapy With Kane handles your data, please review the privacy policy.

Route to Therapy With Kane

01.

Contact using the contact form.

02.

Arrange a free 20 minutes consultation

03.

Decide if you want to work with me

Currently, I offer online only

04.

Arrange your first session

05.

Together we can make goals of your therapy

Contact Kane

First Name

Last Name

Email

Phone

Thank You for Reaching Out!

Email: kane@therapywithkane.co.uk

Phone: 07999 106 164

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Home
About Kane
Start Therapy
Pre-assemement Questionnaire
Fees
Articles
Contact
Privacy Policy

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