Counselling Services • Hamilton New Life Church

Client Information

First Name

Last Name

Mailing Address

Date of Birth

Marital Status

Phone Number

Email Address

Emergency Contact

Name

Contact number

Relationship to Client

Mental Health History

Have you ever been hospitalised for a mental illness?

Yes

No

If yes why were you admitted?

Have you ever been diagnosed with a mental illness?

Yes

No

If Yes, what was the diagnosis?

Do you have an addiction?

Yes

No

Uncertain

If yes what type of addiction?

Do you take recreational drugs?

Yes

No

If yes what kind?

Do you drink Alcohol?

Yes

No

If yes how often and in what quantity?

Have you made any past attempts of suicide?

Yes

No

If yes provide details

Do you have any thoughts of suicide now?

Yes

No

In a few words why would you like to see a counsellor?

Privacy Statement
By completing this form, you acknowledge that the personal and medical information you provide will be passed directly to Adam Appleton the counsellor for the purpose of your care. Hamilton New Life Church do not store, retain, or share this information beyond its intended use. All details remain confidential between you and your counsellor in accordance with applicable privacy laws.