Zainab Therapy Assessment Form

Client Assessment Form

Please complete the required fields of this form at least 12 hours prior to your first therapy session. Failure to complete and submit this form, will result in cancellation of your therapy session. If you have any problem completing the form, please email contact@zainabtherapy.com.

Payment

Please make agreed payment of £35.00 24 hours before your session. Payment details will be sent to you via email or text (Please let me know if you require an alternative payment method).

Availability & Cancellations

Please rearrange/cancel appointments via my calendly schedule. If you need to cancel your session, I ask that you provide me with 48-hours’ notice. Missed sessions without notice will be charged at £20.00.

Confidentiality and Privacy

Confidentiality Information and details of sessions are confidential. This confidentiality does not cover the following:

1. Where I have reason to believe that you may cause serious injury or harm to yourself or to another individual.

2. Where I have reason to believe that someone, especially a child, is at risk of harm.

3. Disclosure of terrorist acts, drug and human trafficking and/or money laundering.

4. Where I am legally compelled to do so. Where possible, my therapist will always inform me first if any information under the above points occurs and the action the therapist will take.

Length of sessions

Therapy sessions are 50 minutes. A minimum of 6 sessions are recommended. We will do a regular review of how the therapy is progressing.

Counsellor Holidays

Holidays will be notified to 2 weeks in advance and my calendly schedule will be updated accordingly.

Crisis outside the counselling session

We are not a crisis support service. Therapy is not available outside the agreed session hours. If support is required outside of therapy hours, please contact Samaritans or Crisis Line 111.

Ethical Framework

My therapist abides by the British Association for Counselling and Psychotherapy “Ethical Framework for Good Practice in Counselling and Psychotherapy”, a copy of which is available on request.

Title

First Name

Last Name

Phone Number

Home Address

Gender

Occupation

Ethnicity

Do you follow a faith? if so, which one?

Do you have any disabilities?

If you have not been referred, please skip this section.

Have you been referred?

Yes No

Date of Referral

Who were you referred by?

What is your preferred language?

GP Surgery Name

GP Surgery Address

GP Surgery Phone Number

Is there any relevant family medical history relating to mental health?, If so please detail below:

Have you had any previous experience of therapy?

Please share the type of therapy you received

What are you seeking support for during your therapy sessions? (OCD, anxiety, depression...)

Please tick the following box to confirm your acceptance of the counselling contract and above terms and conditions.

The points below have been discussed between myself and my therapist, I understand them and agree to work with my therapist within the terms of this agreement. I confirm I have read the counselling contract and terms and conditions. I accept the associated contract and terms and conditions.