MULTIDIMENSIONAL-THERAPY

Monica Erosa – Holistic Counseling | Transpersonal Art Therapy

Client Assessment Form

This assessment form will be kept in strict confidence. The information will help to ensure that the service I provide to you is appropriate to your circumstances and enable me to fulfil my duty of care. Please complete and return this form by or at our initial session.

    (Someone who could be called if you needed support after a session)
    YesNo
    PoorSatisfactoryGoodExcellent
    YesNo
    NeverSeldomLess than twice a weekMore than twice a week
    NeverSeldomLess than twice a weekMore than twice a week
    YesNo
    NeverSeldomLess than twice a weekMore than twice a week
    YesNo
    PoorSatisfactoryGood
    EMOTION   ABOUT? SCORE THIS EMOTION FROM - 0 to 10 SINCE WHEN DO YOU FEEL THIS WAY?
    Fear YesNo
    Fear YesNo