|
Please note that I am unable to
accept any new online clients at present |
|
A client/therapist relationship is confidential. The
obligation to maintain confidentiality continues after the
therapeutic relationship has ended as set out by BASRT's Code
of Ethics by which I am bound.
Please note that a copy of this completed form will be mailed to Partner
A for your records.
Note: Please furnish as much
information as possble to assist in this assessment process.
|
|
Partner A |
Partner B
(if applicable) |
| Title |
|
|
| Forenames |
|
|
| Surname |
|
|
| Date of Birth: (Day/Month/Year) |
|
|
| Gender: |
Male:
Female: |
Male:
Female: |
| Address: |
|
|
|
|
|
| City: |
|
|
| County/Province/State: |
|
|
| Zipcode: |
|
|
| Country: |
|
|
| Occupation: |
|
|
Telephone - Daytime:
Please include country dialing code |
|
|
Telephone - Evening:
Please include country dialing code |
|
|
E-mail address:
(Mandatory for Registration) |
|
|
| I agreed to the Terms
& Conditions: |
Yes
- No |
Yes
- No |
Initial Assessment for Individuals or Couples |
| |
NATURE AND DEVELOPMENT OF YOUR DIFFICULTY
|
| Give a short description of your current difficulties -
including any physical or psychological difficulties you have: |
|
|
| When did it begin? |
|
|
| How and why do you believe it developed? |
|
|
| How do you feel about your difficulty? |
|
|
| Are there any factors which have made it better? |
|
|
| Has the problem been accompanied in other changes in the
relationship between you and your partner (e.g.
loss of affection, impaired communication, rows?) |
|
|
NATURE AND DEVELOPMENT OF YOUR SEXUAL DIFICULTIES (IF
ANY)
|
| Is your loss of interest in sex with your partner complete,
or are you sometimes interested? |
|
|
| Is your difficulty partner-related or is it total? (e.g.
do you have fantasies etc. about other people) |
|
|
| Do you ejaculate (male) or have orgasm (female)? |
|
|
| Does the presenting problem cause physical pain? -if so,
where and what kind of pain? |
|
|
| What do you want out of therapy? |
|
|
| What is your availability for regular therapy and homework? |
|
|
| Please add anything else which you believe is relevant to
your current difficulties |
|
|
MEDICAL
|
| Do you have any illness requiring continual medical
attention? |
|
|
| Have you had surgery? - if so, for what reason? |
|
|
| What medication are you currently taking?(if any) |
|
|
| Do you take any non-prescribed drugs?- if so, what? |
|
|
| Please indicate your weekly level of: |
|
Alcohol |
Alcohol |
|
Smoking |
Smoking |
|
|
|
|
