Confidential Basic Information

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Confidential Basic Informationbthsdadmin2025-10-17T17:57:00+11:00

Narelle Williams | ACA Membership # 3519

Clinical Counsellor, Family Therapist, Advanced Grief Recovery Specialist & Clinical Supervisor
Bethesda Counselling & Family Therapy, Suite 1, No 14 The Avenue, Midland, 6056 WA

Confidential Basic Information

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Date*

MM slash DD slash YYYY

Address:*

Name (Mr, Mrs, Ms, Miss, Other):*

Email*

Home Phone/Mobile*

Year of Birth:*

Next of Kin (name, relationship and contact number):*

Occupation:*

Employed by:*

Name of Private Health Insurance:*

Marital Status (choose one):*

Single

De Facto

Married

Separated

Divorced

Widowed

Religious Affiliation:*

Have you had previous counselling?:*

Yes

No

If yes, what for?*

Are you under current medical treatment?*

Name of Doctor/Psychologist/Psychiatrist:*

Are you taking any medications or prescribed drugs? (If yes, what is the name of the medication and the dose rate?)*

Have you ever been diagnosed with a personality disorder? If yes, please clarify:*

Have you even been admitted to hospital due to a diagnosed incident of psychosis? If yes, Please clarify:*

In your knowledge, have you ever been exposed to a traumatic incident or ongoing trauma? (please check)*

Yes

No

How many standard drinks of alcohol would you consume on average per week?*

Are you using any recreational drugs such as marijuana, Ice or Ecstacy etc? If yes, what and how often?*

Have you ever, or are you currently feeling suicidal?

Past

Current

Never

Who referred you to this practice?*

What is the main problem that you are seeking counselling for?*

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