Pre Assessment Form – helenjames.co.uk

Pre Assessment

Please complete the following form – if you feel uncomfortable with any of the questions, just leave them out.

Any questions ring Helen anytime on 07590489933

This pre-assessment is designed to help you begin to make connections between what has happened in your life and your symptoms. Your completed forms will remain confidential between you and your practitioner. Completing it is voluntary, but will help in your assessment, diagnosis and any follow up advice provided.

Name

Date of Birth

Month

Year

Phone number

Address

Your occupation and briefly what it entails:

Hobbies and sports and whether your symptoms have affected your ability to do them:

Have you ever been in hospital? Please list roughly when and why

What diagnoses have you been given re. your pain and any other health condition? Please include any test results.

What medications do you take presently?

Other mental health practitioner

When did you see your therapist and what for? Just approximate dates and brief description will do

Did you/do you smoke?

Yes No

Do you drink Alcohol?

Yes No

Have you ever used illicit drugs?

Yes No

Do you use illicit drugs?

Yes No

How well do you sleep?

Sexual orientation

Heterosexual Gay Bisexual Other

Religion (past and present, if any)

Please list your MAIN 2 symptoms/problems:
Main symptom/problem 1

Main symptom/problem 2

List the specialists/therapists you have seen and any treatments you have had for these symptoms/conditions.

List any other symptoms that are currently bothering you.

Please answer the questions below for each of the main 2 problems/symptoms you are presenting with.
Symptom 1: When did this symptom begin?

Symptom 2: When did this symptom begin?

Symptom 1: Do you/did you link this to a particular physical cause?

Symptom 2: Do you/did you link this to a particular physical cause?

Symptom 1: What was happening in your life when it began?

Symptom 2: What was happening in your life when it began?

Symptom 1: Give a brief history of how it has been since the onset and whether you can link this with any particular stresses.

Symptom 2: Give a brief history of how it has been since the onset and whether you can link this with any particular stresses.

Symptom 1: Is there a particular time of day or night when it is usually at it’s worst?

Symptom 2: Is there a particular time of day or night when it is usually at it’s worst?

Other: add anything else you think is relevant

How would you describe your relationship with her as a child and now?

Was your Mother loving and affectionate with you, or the opposite? Was her love conditional?

Did she have high expectations of you or was she critical?

Other: add anything else you think is relevant

How would you describe your relationship with him as a child and now?

Was your Father loving and affectionate with you, or the opposite? Was his love conditional?

Did he have high expectations of you or was he critical?

Do you have any step parents and if so when did they come into your life and what influence do you feel they had on you?

Do you have siblings and if so where do you come in the family? Briefly explain what sort of relationship you have/had with them.

Did you have a number of changes during your childhood – such as moving house/school/area, being adopted etc?

Are you currently in a stable relationship? In 3 words how would you describe this?

Do you have children and if so, how old are they?

Do you have any step-children or adopted children?

Select family members that either have or had any disorders or illnesses

Do you find it difficult to express vocally how you feel?

Yes No

How do you deal with stress?

Anything else?

Record any symptoms at the time

I consent to my submitted data being stored for the purposes of handling my enquiry. PRIVACY POLICY

+44 7590 489933

Drop Helen a line to see how she can help you.

Day, Evening and Weekend appointments available.

Pre Assessment

Accreditations and Associations

+44 7590 489933

helen@helenjames.co.uk

Drop Helen a line to see how she can help you.

Day, Evening and Weekend appointments available.