Section 1 – Basic Client Information

Section 2 – Contact Details

Parent/Guardian Details (For Minors)

Emergency Contact

Section 3 – Referral & Presenting Concerns

Main Areas of Concern: Emotional

Main Areas of Concern: Behavioural

Main Areas of Concern: Academic & Career

Section 4 – Developmental & Family History

Developmental Milestones

Sections 5, 6 & 7 – Educational, Medical & Social History

Section 9 – Risk Screening

Section 11 – Goals for Counselling

Section 13 – Consent & Declaration

I confirm that the information provided above is true and accurate to the best of my knowledge. I understand that counselling is a professional supportive process and confidentiality will be maintained within ethical and legal limits.