Earth Wisdom Ecotherapy Community Interest Company

Assessment Session

Date

Client Reference

Have you been in therapy before? What was that experience like?

Do you have supportive people in your life? If so, who?

How is your relationship with your family?

Health/Medical Professional/Agencies involved? Including Medication Details.

Availability for Sessions.

Session Fee Agreed: Means Tested Benefites: £25, Non-Means Tested Benefits £35, Low Income Sliding Scale: £19,999 = £25, £20,000 – £29,999 = £35, £30,000 – £39,999 = £40, £40,000 – £49,999 = £50, £50,000 and Over = £60

What are the goals you want to accomplish in therapy? What do you expect from therapy?

Why are you seeking therapy at this time?

Reasonable Adjustments

Further Information

CORE Score

CORE 10 SCORES

Healthy - 0 to 5, Low - 6 to 10, Mild - 11 to 14, Moderate - 15 to 19, Moderate to Severe - 20 to 24, Severe - 25 and above.

Counsellor Name

Counsellor Surname

Signature

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Earth Wisdom Therapy

info@earthwisdomtherapy.co.uk

Assessment Session

Earth Wisdom Ecotherapy Community Interest Company

Assessment Session