Initial Consultation Form For Mentoring

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 mentoring 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 mentoring BEGINS YOUR DATA WILL BE RETAINED FOR MY REFERENCE PURPOSES ONLY. IF mentoring 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

Why have you chosen to start mentoring?

If you believe it is relevant to our mentoring sessions, please give some information on past or current therapy (type of therapy, why, when, how long, why finished, results).

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, suicidal ideation or attempt, 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).

If you believe it is relevant to our mentoring sessions, please give any information on your 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).

If you believe it is relevant to our mentoring sessions, please give any information on your 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).

If you believe it is relevant to our mentoring sessions, please give any information on your family members or current/ past partners which I may need to know.

If you believe it is relevant to our mentoring sessions, please give any information on your 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, what do you believe in).

If you believe it is relevant to our mentoring sessions, please give any information on your 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).

If you believe it is relevant to our mentoring sessions, please give any information on your 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 sessions 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.