ROBBIE SPENCE

COUNSELLING

Robbie Spence

Clinical Counsellor

robbiespence.com.au

CLIENT WELLBEING FORM

Getting to Know You - EAP Clients

The following online questions can help me understand where you're at so we can make the most of the time we have together. If you prefer to print/complete and scan/email a hardcopy form, download here. Note that this information is NOT shared with your organisation or workplace.

Client Wellbeing Form

First Name

Last Initial

What is your reason for seeking counselling?

Have you attended counselling before? *

Yes

Are you currently seeing a counsellor? *

Yes

Have you ever been hospitalized for a mental health issue? *

Yes

Are you presently off work? *

Yes

For the period of the past 30 days, please total the number of hours your personal concern caused you to miss work. Include complete eight-hour days and partial days when you came in late or left early. *

No Absence (0 hours)

Absent less than half a day (<4 hours)

Absent less than a full day (<8 hours)

Absent from one to three days (8 to 24 hours)

Absent more than three days (25 to 160 hours)

The following statements reflect what you may do or feel on the job or at home. Please indicate the degree to which you agree with each of the statements for the past 30 days. Choose an option on the drop down menu.

My personal problems kept me from concentrating on my work.

I am often eager to get to the work site to start the day.

So far, my life seems to be going very well.

I dread going into work.

Select a date * required

Thank you.

EXPLORE CHALLENGES. BUILD ON STRENGTHS.

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