New Client Questionnaire

Thank you for exploring the Mandy Alexander Counselling Service. To make it easier for us to decide together whether this service is most suited to your needs please fill in the information requested below. Please be assured you will not be commiting to continuing with my service, it will simply help us to ensure you receive the best quality of care.

This questionnaire asks for personal information that may illicit feelings of discomfort. Reveal details as you feel comfortable, and if answering these questions is more difficult than you anticipated, please let me know.

This is a confidential questionnaire that will be communicated via an encrypted email service (Hushmail) and, as such, your information will remain private and confidential.

Personal Information

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Can we leave a message on your phone?

In Case of Emergency

Who should be contacted in case of emergency?

Intake / Background Information

Yes I am interested in Individual Counselling.

Briefly, what is your reason for seeking therapy at this particular time?

Are you experiencing any negative feelings such as: depression, sadness, anger, grief now?

Can you think of anybody in your family or social environment who you regard as, or think could be, an additional source of support?

Can you estimate the severity of the problem for which you are seeking care?

How many sessions or how much time do you think you might need to successfully resolve this problem?

Have you ever been in treatment with a counsellor or therapist in the past?

If yes, when were you treated and for what problem - and was it helpful?

What was the result of this treatment?

Please list any past/present drug and alcohol use. What have you used and how much? What are you currently using and how much? Has it ever affected your work or personal relationships?

Have you ever had cause to see a psychiatrist or receive psychiatric care?

Are you currently taking any medication such as anti-depressants or anti-anxiety? If so, what?

Have you ever felt suicidal or feel that you may be now?

Referral Information

Who referred you and how did you hear about my practice?

Are you interested in traditional, In-person Therapy or Online Therapy? (Face to face therapy is dependent on your location and my availability).

If you are requesting Online Therapy, can you describe your reason for choosing that form of therapy?

Do you have enough physical privacy for engaging in Online Therapy?

If you have chosen Online Therapy, what is your preferred method of communication?

Please check all that you have experience with:

Are you using a PC, Mac or a Mobile Device? Not all encrypted counselling services are compatible with mobile devices.

What kind of platform does your computer use? For example, Windows 7, 8 or 10; Mac OS or Mac OS X etc.

Do you have reliable internet access?

Please use this field for any additional comments or questions you may have:

Your Privacy Assured

By submitting this form you are not committing yourself to my service. You may be assured that the information you submit will remain totally private and confidential and will be seen only by me, Mandy Alexander (MBACP), and only in direct relation to your enquiry. In the event that you decide not to proceed with online counselling, all the information you have submitted will be permanently deleted from my records.

Confirmation of Terms of Service

  • I am over 18 years of age

I confirm that I have read and and fully understand the Informed Consent document and agree to the terms therein.

All finished for now?

Whether you are happy to go ahead, or would like further information, please feel free to get in touch: I'm looking forward to hearing from you!