Toggle navigation
Home
About us
Self-Referral
GP Surgery Referral
Insurance Referrals
NHS Applications
Choose Counsellor
Services
Privately Paid 1-1
Relationship Counselling
Children of Deaf Adults Counselling
Insurance (EAP)
End of Contract Report
Home
/
End of Contract Report
End of Contract Report
Client Information
General information
Client ID
Client number
Report Date
Today's date
Psychotherapist
*
Verity
Jill
Wendy
Caroline
Matthew
Jennifer
Sue
Hazel
Victoria
Jacob
Johanna
Paula
Simone
Dee
Therapist selection
Report For?
*
NHS England
Health Board
Insurance
Legal Report
Donation Funding
Other
Report For?
Who is the report for?
Session Information
Session information
Contracted Sessions?
*
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Other
Contracted Sessions?
Total number of sessions authorised
All Sessions Attended?
*
Yes
No
Each session attended?
Any Sessions Missed?
1
2
3
4
Other
Any Sessions Missed?
Number of missed sessions?
Missed Sessions Reason?
Medical emergency
Forgot session time & date
Forgot session time
Forgot session date
Family emergency
Child care
Other
Missed Sessions Reason?
Reasons for any missed sessions?
Any Additional Information, if none leave blank
Mental Health Issues
The major mental health condition/issue (the number 1 reason for counselling?
Mental Health Issue
Anger
Anxiety
Bipolar
Borderline Personality Disorder (BPD)
Depression
Panic
Post-Traumatic Stress Disorder (PTSD)
Phobias
Stress
Schizophrenia
Trauma
Other
Mental Health Issue
Presenting mental health Issue
Initial Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
Initial Assessment
Counsellor first few sessions assessment
Mid-Term Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
Mid-Term Assessment
Counsellor first few sessions assessment
EOC Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
EOC Assessment
Final status of the client
Any Additional Information, if none leave blank
Mental Health Issues
Co-existing mental health issue
Co-Existing (MHI)
Anger
Anxiety
Bipolar
Borderline Personality Disorder (BPD)
Depression
Panic
Post-Traumatic Stress Disorder (PTSD)
Phobias
Stress
Schizophrenia
Trauma
Insomnia
Other
Co-Existing (MHI)
Only complete if more than 1 mental health issue
Initial Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
Initial Assessment
Only complete if more than 1 mental health issue
Mid-Term Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
Mid-Term Assessment
Only complete if more than 1 mental health issue
EOC Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
EOC Assessment
Only complete if more than 1 mental health issue
Any Additional Information, if none leave blank
Mental Health Issues
Co-existing mental health issue
Co-Existing (MHI)
Anger
Anxiety
Bipolar
Borderline Personality Disorder (BPD)
Depression
Panic
Post-Traumatic Stress Disorder (PTSD)
Phobias
Stress
Schizophrenia
Trauma
Insomnia
Other
Co-Existing (MHI)
Only complete if more than 2 mental health issues
Initial Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
Initial Assessment
Only complete if more than 2 mental health issues
Mid-Term Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
Mid-Term Assessment
Only complete if more than 2 mental health issues
EOC Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
EOC Assessment
Only complete if more than 2 mental health issues
Any Additional Information, if none leave blank
Contributing factors
Emotional Factors for Mental Health Decline
Emotional Health
*
Worry (something dreadful will happen)
Shame (feel inadequate))
Isolated (lonely, no friends)
Worry (pending homelessness)
Death of a parent
Death of a grandparent
Terminal Illness (close friend)
Terminal Illness (family member)
Other
Emotional Health
Emotional factors for mental health decline
Initial Assessment
*
Mild
Moderate
Moderate/Severe
Severe
Other
Initial Assessment
Counsellor first few sessions assessment
Mid-Term Assessment
*
Mild
Moderate
Moderate/Severe
Severe
Other
Mid-Term Assessment
Counsellor first few sessions assessment
EOC Assessment
*
Mild
Moderate
Moderate/Severe
Severe
Other
EOC Assessment
What is the end of contract assessment
Any Additional Information, if none leave blank
Contributing factors (2)
Only complete if more that 1 Emotional Factors for Mental Health Decline
Emotional Health (2)
Worry (something dreadful will happen)
Shame (feel inadequate))
Isolated (lonely, no friends)
Worry (pending homelessness)
Death of a parent
Death of a grandparent
Terminal Illness (close friend)
Terminal Illness (family member)
Other
Emotional Health (2)
Initial Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
Initial Assessment
Mid-Term Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
Mid-Term Assessment
EOC Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
EOC Assessment
Any Additional Information, if none leave blank
Contributing factors (3)
Only complete if more that 1 Emotional Factors for Mental Health Decline
Emotional Health (3)
Worry (something dreadful will happen)
Shame (feel inadequate))
Isolated (lonely, no friends)
Worry (pending homelessness)
Death of a parent
Death of a grandparent
Terminal Illness (close friend)
Terminal Illness (family member)
Other
Emotional Health (3)
Initial Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
Initial Assessment
Mid-Term Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
Mid-Term Assessment
EOC Assessment
Mild
Moderate
Moderate/Severe
Severe
Other
EOC Assessment
Any Additional Information, if none leave blank
Unmet Needs
Remaining Unmet Needs
Remaining Unmet Needs
Are there any issues that have not been resolved?
Discharge Notice
*
Client responded well with no further counselling required at this time
Client could require additional sessions in the future
Client should not end counselling due to high risk factors
Client has potential upcoming event that could require an additional counselling requirement
NHS rejected extension to sessions
Counsellors assessment of the discharge of the client (use text-box above to add any information that supports your answer)
Any Additional Information, if none leave blank
Submit
If you are human, leave this field blank.
Contact Us
Contact Form
WhatsApp
Email
01932 881849
SMS
Facebook
Twitter
→
Home
Return Home Page
Self-Refer
Self-Referral
GP
GP Referral
EAP
Employment Support
Team
Choose Counsellor
Pay
Pay for Sessions