Psychological Initial Assessment

1. Basic Information

Personal Details

Full Name *

Age *

Gender *

Preferred Language *

Contact Phone Number *

Email Address *

2. Reason for Consultation

What brings you for counselling/psychological support today? *

When did this concern begin? *

How is it affecting your daily life, work/studies, relationships, or sleep?

3. Current Emotional Well-being

How have you been feeling recently?

Select all emotional states that describe your recent mood.

4. Current Difficulties

Select all areas of difficulty that apply:

5. Severity Rating

On a scale of 0–10, how much is this concern affecting you currently?

0 = Not affecting me | 10 = Extremely difficult

Selected Severity Rating:

6. Sleep & Daily Functioning

Physical & Daily Impact

How would you describe your sleep recently?

Impact on appetite, energy, concentration, or daily functioning?

7. Previous Support

Have you previously received counselling or psychological/psychiatric support?

No Yes

8. Medication / Medical Factors

Are you currently taking any medication or receiving treatment relevant to your mental well-being?

9. Safety Screening During the past few weeks, have you had thoughts of harming yourself or feeling that life is not worth living?

10. Goals & Objectives

What would you most like to achieve?

What would you most like to achieve through counselling? *

11. Immediate Support Do you feel you need urgent psychological support at this time?

No Yes — Need Urgent Support

12. Consent & Acknowledgment I understand that this form is used for an initial psychological assessment and does not constitute a formal psychiatric diagnosis. I consent to discussing the information provided with the clinical team/psychologist.