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Assessment – NHS – Louise – WU2725078
Client
Counsellor
Questionnaire
Yes
Questionnaire
Evelyn Bennis Date of Birth? 31/07/1948 Phone Number 07701090973/ 02089503262 Email evelynbennis@btinternet.com Gender? F Surgery Name Schopwick surgery Dr Name (if Known) DR timminis Postcode WD23 Relationship? Divorced Have you got a carer? Yes – Part-Time Employed? No Are You Medically or Physically Able to Work? No Vision Scale Blind (100%) Vision? Both eyes Reasoning? Unexplained (Sudden Acquired) Do you feel your vision loss is the basis of your mental health issues? Yes Mobility Device? Walking stick Medication? (multi-select if needed) None Any Medical Issues? Yes Anything to add Medically? Birdshot Chorioretinopathy – cause – end stage – first eye 20+ years left eye – at end stage autoimmune disease Sarcoidosis lichenpelnls Multi-Select Available Anxiety, Depression, Health Anxiety Continued Social Anxiety Any, Past Counselling? Yes How Were They Funded? NHS Approx When? This year Approx Number of Sessions 10 Please explain as briefly as possible what your current issues are? rnib – 6 x 6 sessions 1990 + 2025
Emotional Regulation Section
Intensity – Emotions are experienced with extreme intensity, far greater than the situation might warrant
*
No
Rarely
Occasionally
Often
Mostly
Always
Other
Other
Recovery – Difficulty in returning to a baseline emotional state after being triggered
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No
Rarely
Occasionally
Often
Mostly
Always
Other
Other
Impulse Control – Challenges in controlling impulsive behaviours when experiencing strong emotions
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No
Rarely
Occasionally
Often
Mostly
Always
Other
Other
Interpersonal Relationships – Frequent and intense emotional responses can strain relationships with others
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No
Rarely
Occasionally
Often
Mostly
Always
Other
Other
Duration – Emotional responses are prolonged, lasting longer than typical reactions
*
No
Few Days
Most Days
Almost Every Day
Other
Other
Internalising Disorders: Emotions are directed inward, leading to challenging emotional states
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No
Occasionally
Rarely
Often
Mostly
Always
Other
Other
Trauma-Related Disorders: Post-traumatic stress disorder (PTSD) and complex PTSD, which often involve severe emotional dysregulation.
*
No
Occasionally
Rarely
Often
Mostly
Always
Other
Other
Externalising Disorders: Emotions are directed outward, resulting in aggressive, disruptive, or antisocial behaviors. Examples include oppositional defiant disorder (ODD) and conduct disorder (CD).
*
No
Occasionally
Rarely
Often
Mostly
Always
Other
Other
Disability
Describe the clients disability
*
What is the disability, how did they get it, what co morbidities have they got, this is a general question about the disability.
Mental Health
Describe the clients mental health
*
What we are looking for is “What, How and Severity” This is based on a assessment session and is not a diagnosis
Social History
Describe the clients daily life
*
What does a normal day look like and how does it effect them
Therapy History and Expectations
What do they want to get out of counselling?
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Risk
What Factors create risk to this person
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Include Triggers, Suicidal Thoughts, Self-Harm Thoughts any Past Suicidal or Self-Harm Actions.
Free Writing
Add relevant Information about the client that has not been covered.
Any, other information
*
Submit
If you are human, leave this field blank.
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