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Earth Wisdom Therapy

info@earthwisdomtherapy.co.uk

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Date*

Client Reference *

Previous Therapy Experience*

Support Network*

Family Relationships*

School, College, or Work

Neurodiversity and Learning Preferences

Wellbeing Overview - Sleep, Movement, and Nourishment

Hobbies and Interests

Availability for Sessions.*

Hopes for Therapy*

Starting Therapy*

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

Is there any risk of harm to self or others?*

Self-harm

Suicide

Violent Behaviour

Substance Misuse

Domestic Abuse

Mental Health Crisis

Safeguarding of Children

Safeguarding of Adults

None

Other

Further Information

CORE Score

Additional Information

Counsellor Name*

Counsellor Surname*

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