Client Background Information
Name:
Identification card no:
Permanent Address:
Current Address:
Date of Birthday:
Gender:
Nationality:
Religion:
Contact Number:
What is the reason you get counseling?
Have you ever sought counselling and Session Duration?
Family Information
Number of siblings
Father/ guardian's occupation
Mother's/ guardian's occupation
Household income
Parental marital status
Individual to be contacted during emergency
Name
Relationship
Address
Mobile Number
EDUCATION BACKGROUND
Your highest academic achievement
Your involvement in sports activities
Involvement in Clubs/ Associations/ Uniform Units
GENERAL HEALTH CARE AND MENTAL HEALTH
Have you attended any counselling session/guidance/ psychotherapy?
Have you took any prescribed medicines from any professional?
Have you been prescribed with any medicines related to psychiatric treatment?
Based on 5-scale below, please state your level of physical health.
Based on 5-scale, please state your satisfaction on your sleep quality.
How often do you exercise in a week?
Please state your eating behavior
Encountered any Situations
Have you encountered any situations as below:
1. The lost of significant person in life
Period of time
2. Sadness
Period of time
3. Depression
Period of time
4. Anxiety
Period of time
5. Panic attack
Period of time
6. Phobia
Period of time
GENERAL HEALTH CARE AND MENTAL HEALTH
Substance Abuse
Have you took any of these substances. Please state if it is related.
1. Drug
Period of time
2. Tobacco
Period of time
3. Substance
Period of time
4. Alcohol
Period of time
5. Pills abuse
Period of time
6. State
Period of time
Misconduct
Have you ever involved in any misconducts below:
1. Gambling
Period of time
2. Stealing
Period of time
3. Watching pornography
Period of time
4. Bullying
Period of time
5. Beating / cause injury to other person
Period of time
6. Cause damage to other’s property
Period of time
7. Threaten others
Period of time
8. Sexual misconduct
Period of time
GENERAL HEALTH CARE AND MENTAL HEALTH
Do you have any chronic disease?
Specify
Do you have any girlfriend/ boyfriend?
If yes, based on 10-scale below, state your level of satisfaction in your relationship.
I have a strong religious conviction
Based on 10 scale, state your level of satisfaction in your family relationship.
Individual in your life
A significant individual in your life.