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IMG_1958 2.HEIC

Pre-assessment Questionnaire 

Please fill out this questionnaire ahead of your free 20 minutes consultation call.

If you have not yet booked a consultation, I will contact you via the email address provided in this questionnaire to arrange an appointment with you.

I will only ever use this information in the case of an emergencies where this information might be needed.

Date of birth
Day
Month
Year
Is your gender the same as that assigned at birth?
Yes
No
Prefer not to say
In a scale of 1 - 5, with 1 being lowest (worst) and 5 being the highest (best), how would you rate your mental health in the past two weeks?
1 (lowest)
2
3 (neutral)
4
5 (highest)
Do you still have contact with family?
Yes
No
Do you have any mental health or physical health diagnoses?
Yes
No
Under assessment
Unsure
Are you on any medication?
Yes
No
Do you have a history of, or currently a victim of domestic abuse?
Yes
No
Unsure
Prefer not to say
What is your availability? (select all that apply)

Please tell me any availability that is not listed above for example evenings, as I have some evening slots.

I will only use your GP details when required to do so if I believe you are at harm to yourself or others.

To find out how Therapy With Kane handles your data, please review the privacy policy.

Route to Therapy With Kane

01.

Contact using the contact form.

02.

Arrange a free 20 minutes consultation

03.

Decide if you want to work with me

Currently, I offer online only

04.

Arrange your first session

05.

Together we can make goals of your therapy

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