IMPORTANT: The completion and return of this form confirms that you understand and agree with the Terms and Conditions of Consulting with Pollin Kamell, as listed at the end of this form. A copy will be kept on file.
*** PERSONAL DETAILS
Date of birth
Contact (Email / Mobile / Home / Work)
*** WHAT BROUGHT YOU TO SEEK THERAPY
What is you greatest struggle / main issue?
How do you experience it? How do you think or hope I can help?
How do you relate to the world these days? What is the overall feeling you experience in any given day? How or what do you feel normally?
*** PAST AND CURRENT THERAPY HISTORY
Have you had or are you still having any form of therapy / counselling / support / alternative treatment? Please list the Therapy type, Frequency and Issues addressed
*** MEDICAL AND HEALTH CARE HISTORY
Please outline any specific health or mental conditions that you may have been diagnosed with. Have you been admitted into hospital, institution or care previously? (If so, please outline briefly)
*** MEDICATION DETAILS
Please list all natural or pharmaceutical (prescribed or over-the-counter) medications ... inclusive of any drugs, prescribed or recreational and/or supplements. Please include name, dosage and frequency.
*** RELIGIOUS OR SPIRITUAL BACKGROUND
What is the religious or spiritual background of your family? Has this changed at any point and if so, how?
What are your personal beliefs about life?
*** ADDITIONAL INFORMATION
Is there any additional information you think I should be aware of?
*** TERMS AND CONDITIONS OF CONSULTATION
I hereby confirm that (please tick each point as you read them)
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