Initial Consultation Form

The purpose of this initial consultation form is for you to provide me, Jasmine Jarchevska, BA (Hons), Dip. Psych., UKCP Accred. (https://nursethesoul.com/about/), with information before beginning therapy together.

everything you write is strictly confidential. When you press send at the end of filling out the form i will receive it straight to my email inbox. Once the therapy begins your data will be retained for my reference purposes only. If therapy cannot be offered your data will be securely destroyed unless otherwise discussed.

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Name

Age

Date of birth

Place of birth

Gender

Nationality

First language

Address

Emergency contact (Name and number).

Doctor’s name and address (If you do not have a doctor you will need to register before we begin sessions).

Presenting issue(s) (Why have you chosen to start therapy, history of issue(s), symptoms, general mood, emotions).

Current and previous therapy (Who, why, when, how long, why did it finish, outcome).

Medical history (Medical conditions, disabilities, learning difficulties, current medical issues, current supplements and medications – specify dosages and how long you have been taking them for, psychiatric history, hospitalisations, surgical trauma issues, major accidents, plastic surgery, abortions, miscarriages, allergies, other).

Substance use (History, when started, type, quantity, drug of choice, alcohol, tobacco, drugs, other, treatment programs – where, when, whether completed, how you experienced it).

Abuse (History, experience of neglect, emotional abuse, physical abuse, sexual abuse – have you ever been the recipient inside or outside of the family of unwanted inappropriate sexual acts).

Suicide (Ideation, attempt, when, under what circumstance).

General health (Physical health, energy levels, sleep and duration, diet, nutrition, what is your eating like, what do you eat in a day, exercise, past/ present eating related issues, feelings around body/ weight/ skin, any cosmetic procedures, when period started and how is your menstruation cycle now if applicable).

Early life (Mother’s pregnancy, birth, breastfed, childhood traumas, childhood illnesses, separations, abandonment, what family life was like, how parents and siblings were experienced, what were your favourite toys, did you have an imaginary friend, memories of being at school, early childhood friends, other important relationships ie nannies, teachers, who was there for you growing up).

Childhood dream(s) (What were your childhood dreams).

Mother (Name, age, occupation, where living, marital status, how you experience her, dynamics of your relationship with her, dynamics of her relationship with your father, dynamics with you as a child, dynamics with your siblings/ partner/ children if appropriate, substance use, mental health issues, emotional health issues, physical health issues, brief medical history that you know of, spiritual beliefs, if passed when did this happen and under what circumstance).

Father (Name, age, occupation, where living, marital status, how you experience him, dynamics of your relationship with him, dynamics of his relationship with your mother, dynamics with you as a child, dynamics with your siblings/ partner/ children if appropriate, substance use, mental health issues, emotional health issues, physical health issues, brief medical history that you know of, spiritual beliefs, if passed when did this happen and under what circumstance).

Step Mother/ Step Father [if applicable] (Name, age, occupation, where living, marital status, how you experience her/ him, dynamics of your relationship with her/ him, dynamics of their relationship with your mother/ father, dynamics with you as a child if appropriate, dynamics with your siblings/ partner/ children if appropriate, substance use, mental health issues, emotional health issues, physical health issues, brief medical history that you know of, spiritual beliefs, if passed when did this happen and under what circumstance).

Siblings [if applicable, begin with the eldest] (Name, age, occupation, where living, marital status, how you experience her/ him, dynamics of your relationship with her/ him, dynamics of their relationship with your mother/ father, dynamics with you as a child if appropriate, dynamics with your other siblings/ partner/ children if appropriate, substance use, mental health issues, emotional health issues, physical health issues, brief medical history that you know of, spiritual beliefs, if passed when did this happen and under what circumstance).

Children [if applicable, begin with the eldest, note some of these questions are only appropriate for adult children] (Name, age, occupation, where living, marital status, how you experience her/ him, dynamics of your relationship with her/ him, dynamics of their relationship with their other parent, dynamics of their relationships with their grandparents, dynamics with their other siblings/ partner/ children if appropriate, substance use, mental health issues, emotional health issues, physical health issues, brief medical history that you know of, spiritual beliefs, if passed when did this happen and under what circumstance).

Other significant family members [if applicable, e.g. grandparents, other relatives] (Name, age, occupation, where living, marital status, how you experience her/ him, relationship dynamics with you and others in the family, substance use, mental health issues, emotional health issues, physical health issues, brief medical history that you know of, spiritual beliefs, if passed when did this happen and under what circumstance).

Brief family health history if not previously mentioned (Please include maternal and paternal grandparents health and if they passed because of an illness please write what kind).

Current relationship(s) [if applicable] (Name, age, occupation, where living, marital status, how you experience her/ him, dynamics of relationship, children if appropriate, substance use, mental health issues, emotional health issues, physical health issues, brief medical history that you know of, what’s the day to day like in this relationship?).

Most important previous relationship(s) [if applicable] (Name, age, occupation, where living, marital status, how you experience her/ him, dynamics of relationship, children if appropriate, substance use, mental health issues, emotional health issues, physical health issues, brief medical history that you know of, reason ended).

Pet(s) [present or past important pets] (Name, age, personality, relationship).

Education (State, private, boarding, religious, international, Steiner, Waldorf, Montessori, a levels subjects, higher education, which university, post grad qualification, current studies and courses, names of qualifications, how you experience(d) your education, thoughts on education, how you feel about learning and studying, what was a personal choice and what was influenced by parents and/ or what others were doing).

Occupation and work history (Past and present, what kind of work, how do you feel about it).

Inner work history (Is there anything you want to share that you haven’t previously mentioned on any inner work you’ve experienced or are interested in? For example, Transpersonal and Jungian psychology, retreats, shamanic work, astrology, shadow work, EMDR, family constellations, body work, deep interest in ‘X’ which you read/ listen to podcasts on/ watch YouTubes on/ go to seminars on/ go to conferences on/ go to meet ups on, dream work, art therapy, music therapy, dance therapy, myth, tarot, naturopathy, inner child work, breath-work, meditation, plant medicine, workshops, circles, spiritual groups you’re a part of, yoga, rituals, sponsor relationship etc).

Spirituality (Religion, beliefs, family, religious pressures by family, spiritual practices, spiritual experiences, what do you believe in).

Near death experiences (Have you ever had a near death experience? Describe below, please put the date if you remember when).

Sexuality and gender (Are you currently struggling with any sexual or gender related issues e.g. intimacy issues, yours or your partner’s loss of sex drive, painful sex, bdsm, fetishes, sex addiction, sexual orientation, transitioning, are you happy with your sexuality, are you happy with your gender).

Social relationships (How many friends do you have, are they close, how do you experience the quality of your friendships).

Protective factor (What gives you strength, what keeps you going).

Goals, hopes and dreams for therapy and your life

Any other significant factors (Cultural issues, ethnic issues, travel, finances).

Are you currently involved in any legal issues?

Am I connected with any of your friends or family?

Is there anything that hasn’t been mentioned that you feel is important?

I’ve asked you so many questions, is there anything you want to ask me?

By returning this form, you accept that under the General Data Protection Regulations I can process and retain your personal data for the purpose of consultation.

It shouldn’t take me longer than 48 hours to send you a email saying that I’ve received your form. If you haven’t received a message from me please check in with me and ask if I’ve received it via email jasmine@nursethesoul.com or message +447545913193.

Nurse The Soul

A beautiful and balanced life begins with exceptional therapy.