Assessment Date:
{{xmp.r['AssDateView']}}

Location:

Location Date is required

Firstname:

Firstname is required

Lastname:

Lastname is required

Date of birth:
{{xmp.r['DobView']}}

Date of Birth is required

Age autocalculation: {{xmp.r['Age']}}

Email:

Email is required

This is not a valid email address.

Phone:

* no spaces

Not a valid phone number

Format must be as a phone number

Mobile:

* no spaces

Not a valid phone number

Format must be as a phone number

Address 1:

Address1 is required

Address 2:

Address2 is required

Address 3:

Address3 is required

Town:

Town is required

County:

County is required

Postcode:

Postcode is required

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

you must enter more than 5 characters

8 characters maximum

Modality:

Give further details (e.g. Zoom):

Please keep within 1000 characters (approx 140 words)

Preferred Counsellor:

Source of Referral:

Source of Referral is required

Do you know anyone at Redlands:

If yes give details:

Please keep within 1000 characters (approx 140 words)

Further details are required

Are you involved in any legal proceedings?:

If yes give details:

Please keep within 1000 characters (approx 140 words)

Further details are required

Doctors Name & Address:

Required

Please keep within 1000 characters (approx 140 words)

Doctors Name & Address is required

Medication:

Please keep within 1000 characters (approx 140 words)

Previous Psychiatric History:

If yes give details:

Please keep within 1000 characters (approx 140 words)

Further details are required

Previous Counselling History:

If yes give details:

Please keep within 1000 characters (approx 140 words)

Further details are required

Background

Were they adopted or fostered?:

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)

Siblings?:

If yes give details:

Please keep within 1000 characters (approx 140 words)

Further details are required

Relationship in Family:

Significant Relationships:

Please keep within 1500 characters (approx 210 words)

Marital Status:

History:

Please keep within 1000 characters (approx 140 words)

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)

The form is not yet complete

	Morning	Afternoon	Evening
Monday
Tuesday
Wednesday
Thursday
Friday

Entry Form Review Page

Counselling Process Form Submitted

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

Background