Enhanced Client Form Review | Redlands Counselling and Training

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Enhanced Counselling Process Form Submitted

The form has been submitted and email trigger E2 has been sent to the test counsellor.



Client: {{xmp.r['Firstname']}} {{xmp.r['Lastname']}}



Client ref: {{xmp.r['ClientRef']}}



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Counsellors Name is required

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Counsellor Email is required

This is not a valid email address.


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Appointment Time : {{xmp.r['AppHour']}}:{{xmp.r['AppMinute']}}



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Location Date is required

*

Firstname is required

*

Lastname is required


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Date of Birth is required

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*

Email is required

This is not a valid email address.

* no spaces

Not a valid phone number

Format must be as a phone number

* no spaces

Not a valid phone number

Format must be as a phone number

*

Address1 is required

*

Address2 is required

*

Address3 is required

*

Town is required

*

County is required

*

Postcode is required

Postcode format: A12 3CD (3 or 4 digits then 3 digits)

you must enter more than 5 characters

8 characters maximum

Availability for Counselling:

Morning Afternoon Evening
Monday
Tuesday
Wednesday
Thursday
Friday

Give further details (e.g. Zoom):

Please keep within 1000 characters (approx 140 words)
*

Source of Referral is required

If yes give details:

Please keep within 1000 characters (approx 140 words)

Further details are required

If yes give details:

Please keep within 1000 characters (approx 140 words)

Further details are required

Required
Please keep within 1000 characters (approx 140 words)

Doctors Name & Address is required

Medication:

Please keep within 1000 characters (approx 140 words)

If yes give details:

Please keep within 1000 characters (approx 140 words)

Further details are required

If yes give details:

Please keep within 1000 characters (approx 140 words)

Further details are required



Background


If yes give details:

Please keep within 1000 characters (approx 140 words)

Further details are required

Parent/Carer History:

Please keep within 1000 characters (approx 140 words)

Childhood Memories:

Please keep within 1000 characters (approx 140 words)

School Life:

Please keep within 1000 characters (approx 140 words)

If yes give details:

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Further details are required

Significant Relationships:

Please keep within 1500 characters (approx 210 words)

History:

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Occupational/Current Work Life:

Please keep within 1000 characters (approx 140 words)

Feelings about Self:

Please keep within 1000 characters (approx 140 words)

Suicide Ideation/Attempts:

Please keep within 1000 characters (approx 140 words)

Bullet points of presenting problems:

Please keep within 1000 characters (approx 140 words)

Overall Assessment:

Please keep within 2500 characters (approx 300 words)

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