Precounselling Information Form
Name (can be screen name)
E-Mail
Age / gender / relationship status
Geographical location
Describe what you need from therapy
Describe your problem
What drugs do you take
No Medication
Anti Depressants
Anti Anxiety
Anti Psychotic
Herbal
Homeopathic
Other
Frequency /dose/ type
Do you use alcahol / how much ?
Are you consulting any of the following
General Practitioner
Psychiatrist
Psychotherapist
Counsellor
Other Practitioner
No Nobody
Please specify frequency & time length
How do you feel about yourself ?