Counselling Screening Form

Do you mind answering a few questions before your upcoming counselling session? This may take about 30 minutes.

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Client Name *

First

Last

Date of Referral

Date of Screening

Screened by

Has the client stated they have child(ren)? *

• Yes (confirm children's details)
• No (skip to question 5)

Which of the following best describes the contact you have with your child(ren)? (Please select all that apply) *

• Full time primary carer
• Regular part-time care
• Some access visits
• Very little or no contact
• Other

If 'other' please explain

Do you have any concerns about your children's safety or wellbeing at the moment? *

• Yes
• No
• Sometimes

Please provide details of any concerns:

Has the Department of Child Protection and Family Support Services ever been involved with the family? (Please select one only) *

• Yes, for less than 6 months
• Yes, for more than 12 months
• No

Have any of your children aged between 0-17 years been the subject to a child protection substantiation? *

• Yes
• No
• N/A

Do you or your family have any financial concerns (managing money, buying food, gambling debts, paying bills and rent)? *

• Yes
• No

If 'yes', please provide details of any concerns

Do you or your family have any mental health illnesses or concerns? *

• Yes
• No

If 'yes', please provide details

Do you struggle with, or have any concerns with managing your feelings or emotions (e.g. anger, sadness, worrying)? *

• Yes
• No

If 'yes', please provide details of any concerns and how it impacts on you, your family, relationships and life

Have you or do you use alcohol? *

• Yes
• No

If Yes: How frequently do you use alcohol? *

• Daily
• Weekly
• Other

If 'other', list the frequency

Have you or do you use drugs, other than for medical purposes? (Please select all that apply) *

• No
• Inhalants
• Illegal drugs
• Prescription/ over the counter drugs

Please provide details

How frequently do you use drugs? *

• N/A
• Daily
• Weekly
• Occasionally
• Other

What is the impact of your alcohol and/or drug use on you, your family, relationships and life?

Have you been convicted or charged with a crime? *

• Yes
• No

If YES, please provide details of the crime:

Are there any current legal issues affecting your relationships, children, household, tenancy etc. (VRO, custody disputes)? *

• Yes
• No

If YES, please provide details

Do you have any reason to be concerned about your own safety? *

• Yes
• No
• Sometimes

Please provide details of any concerns

Are you linked in with any other services? *

• Yes
• No

If YES, please provide details:

If YES, are you willing to allow Redeemed Care to seek their input?

• Yes
• No

If YES, please provide contact person for each service:

Submit