Name: _ _ _ _ _ _ Gender: _ _ _ _ _ Age: _ _ _ _ _ Class: _
Tel: _ _ _ _ _ Emergency contact: _ _ _ _ _ _
Consultation Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Home address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Family interpersonal relationship: good or bad?
Brothers and sisters ranking: only child? The oldest child? Last child? Intermediate children
Interpersonal relationship: good or bad? _
Reason for visit: (tick the corresponding question)
Learning problems, emotional problems, illness.
Personality problems, interpersonal relationships, lack of affection? Life is hard?
Other issues
Present the main symptoms
Anxiety? Nervous? Insomnia and inferiority? Move more? Irritated? Fear? Depression?
Lack of confidence? Memory loss? Can't concentrate
Others:?
physical condition
Normal? Dizziness and palpitations? Loss of appetite? Gross? Chest tightness? My body is hot and cold.
Others:?
What is the extent of the current problem or symptom? Mild, moderate and severe?
Time and reason of occurrence _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_____________________________________________________________________?
Consultant: _ _ _?
_ _ _ _ year _ _ month? sun
XX psychological counseling room