Assessment Session Assessment Session Assessment Session The assessment session should not be formatted, it should be an open conversation with the client where you gain information. Please don’t use this form as question and answer within the session. If there is information you have not got from your session please don’t worry, we will go back to the client and clarify anything. This form is created to make the report as easy to use as possible. All information you input into this form is confidential & will not be shared with any organisation, company or other entity. The information you input into the form you are not liable for, we secure the information. The assessment session does not represent a diagnosis, its a generalised set of information you provide to help us with the application for the client. Client Information Therapist? * What for? * AmputeeAutismBrittle BonesBSLCarersCerebral PalsyCochlear ImplantsChronic PainCODADyslexiaEpilepsyHard of HearingHead InjuryMultiple SclerosisMuscular DystrophyParkinson's DiseaseRoad TrafficSpinal Cord InjurySpina-BifidaSight LossTinnitusVestibularOther What for? Date of Assessment Session * Client Initials * Risk Assessment Any Past Suicide Attempts? * NoYes Any Current Suicidal Thoughts? * NoYes Do you feel so bad that they think of killing yourself? * NoYesOther Do you feel so bad that they think of killing yourself? Do You Feel Like Life is Not Worth Living? * NoYesOther Do You Feel Like Life is Not Worth Living? Have You Made Plans To End Your Life? * NoYesOther Have You Made Plans To End Your Life? Any thoughts Self Harm? * NoYes Any Self Harm Episodes? * NoYes Suicidal Risks? (Client Responce) Self-Harm? (Client Responce) Risk Other Emotional Health Are relationships are intense, unstable, and alternate between the extremes of over idealising and undervaluing people who are important to you YesNoSometimesOther Are relationships are intense, unstable, and alternate between the extremes of over idealising and undervaluing people who are important to you Can your emotions change quickly, and experience intense episodes of sadness, irritability, and anxiety or panic attacks YesNoSometimesOther Can your emotions change quickly, and experience intense episodes of sadness, irritability, and anxiety or panic attacks Is your level of anger is often inappropriate, intense, and difficult to control. YesNoSometimesOther Is your level of anger is often inappropriate, intense, and difficult to control. Now, or in the past, when upset, have you engaged in recurrent suicidal behaviours, gestures, threats, or self-injurious behaviour such as cutting, burning, or hitting YesNoSometimesOther Now, or in the past, when upset, have you engaged in recurrent suicidal behaviours, gestures, threats, or self-injurious behaviour such as cutting, burning, or hitting Have you got a significant and persistently unstable image or sense of self, or what you truly believe in YesNoSometimesOther Have you got a significant and persistently unstable image or sense of self, or what you truly believe in Do you engage in two or more self-damaging acts such as excessive spending, unsafe and inappropriate sexual conduct, substance abuse, reckless driving, and binge eating YesNoSometimesOther Do you engage in two or more self-damaging acts such as excessive spending, unsafe and inappropriate sexual conduct, substance abuse, reckless driving, and binge eating Do you suffer chronic feelings of emptiness and boredom YesNoSometimesOther Do you suffer chronic feelings of emptiness and boredom Do you engage in frantic efforts to avoid real or imagined abandonment by people who are close to you YesNoSometimesOther Do you engage in frantic efforts to avoid real or imagined abandonment by people who are close to you Addictions? Substance Abuse? NoYesOther Substance Abuse? What? (Multi Select) Cannabis Cocaine Social drugs Alcohol Prescription drugs Pain killers OtherOther Canabis Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Cocaine Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Social Drugs (general) Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Alcohol Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Prescription Drugs Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Pain Killers Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Other Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Anxieties Mental Health? (Multi-Select Options) Each one you select will open up a new section; only select if you feel it’s relevant to your client. This is not an exact science, it must be generalised based on assessment session only. Anxieties logo acf-forms activecampaign authorize aweber bootstrap campaignmonitor constant_contact getresponse googlesheets highrise hubspot mailchimp mailpoet paypal icon polylang salesforce salesforcealt stripe stripealt twilio woocommerce Zapier required delete move drag clear noclear duplicate copy clone tooltip tooltip_solid forbid checkmark image checkmark circle checkmark square check check1 plus plus1 plus2 plus3 plus4 minus minus1 minus2 minus3 minus4 cancel cancel1 close report_problem_solid report_problem arrowup arrowup1 arrowup2 arrowup3 arrowup4 arrowup5 arrowup5_solid arrowup7 arrowup6 arrowup8 arrowdown arrowdown1 arrowdown2 arrowdown3 arrowdown4 arrowdown5 arrowdown5_solid arrowdown7 arrowdown6 arrow_left arrow_right filter download upload2 download2 hard_drive pencil_solid pencil pencil-message signature register account_circle_solid account_circle address_card paragraph checkbox_unchecked checkbox checkbox_solid dropdown caret_square_down radio_unchecked scrubber location_solid location toggle_on toggle_off shield_check shield_check_solid clock clock_solid email_solid mail_bulk code tag tag_solid price_tags search sitemap file file_text_solid file_text option option_solid more_horiz more_vert more_horiz_solid more_vert_solid calculator key key Filled Key Icon keyboard eye eye_solid eye_slash_solid page_break view_day attach_file printer header h1 repeat repeater save sliders code_commit star star_full star_half star_feedback linear_scale pie_chart stats_bars sms feed align_right align_left button browser cloud_upload_solid shuffle swap pallet fingerprint ghost heart_solid heart history import export label_solid label lock_open lock alt_lock dollar_sign percent notification external_link pageview_solid pageview settings stamp support text white_label building icontact sendinblue sendy wordpress credit_card credit_card_alt cc_amex cc_discover cc_mastercard cc_visa cc_paypal icon cc_stripe price product total quantity directory Preview Generalised Anxiety Panic Attacks Stress Obsessive-compulsive disorder (OCD) Phobias Post-traumatic stress disorder (PTSD) Other General Anxiety Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Panic Attacks Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Stress Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. OCD Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Phobias Severity MildModerateSevere Frequency Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. PTSD Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Other Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Depression Mental Health? (Multi-Select Options) Each one you select will open up a new section; only select if you feel it’s relevant to your client. This is not an exact science, it must be generalised based on assessment session only. Depressions Generalised SAD Post-Natal Other Generalised Depression Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Seasonal Effected Disorder Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Post-natal Depression Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Other Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Identity? (Multi-Select Options) Each one you select will open up a new section; only select if you feel it’s relevant to your client. This is not an exact science, it must be generalised based on assessment session only. Identity Anger Rage Isolation Low Self-esteem Feelings of Discrimination Other Anger or Rage Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Isolation Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Low Self-Esteem Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Discrimination Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Other Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Other? (Multi-Select Options) Each one you select will open up a new section; only select if you feel it’s relevant to your client. This is not an exact science, it must be generalised based on assessment session only. Other (this is not a diagnosis, its opinion based) Insomnia Interrupted Sleep Poor Eating Habits Bulimia Anorexia Poor Body Image Body Dysmorphic Disorder Chronic Pain General Pain Other Sleep Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Food Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Body Image Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Pain Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Other Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Childhood through to 18 Childhood Issues? (Home) NoYes What? General Bullying General Abuse Sexual Abuse Poor Health Mobility Issues Other General Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Bullying Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. General Abuse Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Sexual Abuse Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Poor Health Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Other Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. School, College, University Any Issues? (Education) NoYes What? General Bullying General Abuse Sexual Abuse Poor Health Mobility Issues Other General Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. General Abuse Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Bullying Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Sexual Abuse Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Poor Health Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Mobility Issues Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Other Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Relationships (as adult) If required, multi-select relationship. In the box provided, you can elaborate. Relationships (Romantic or Carers) Live with (partner) Carer (my carer) Partner (not living with) Guide or Assistance Animals Pets Other What? No Issues General Bullying General Abuse Sexual Abuse Financial Abuse Control Grief Other General Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Bullying Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. General Abuse Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Sexual Abuse Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Financial Abuse Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Grief Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Control Severity MildModerateSevere Frequency (based on a week) Few DaysMost DaysAlmost Every Day How does it effect them? As brief as possible. Other Severity MildModerateSevere Frequency (based on a week) Few DaysMost Days How does it effect them? As brief as possible. Would you like to add anything that is disability or injury specific? Relevant to the application? NoYes Summary Recommendation? Can you work with this client? YesNo How many sessions do you recommend we apply for? 6-1213-1516-2021-2526-30Other How many sessions do you recommend we apply for? If you are human, leave this field blank. Submit
