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Welcome to Online Counselling South Africa and thank you for making contact.
Before beginning your counselling, we need to know more about you and the difficulty that has brought you to us. To help us to understand you a little better, could you complete this information form. All information gathered here will be treated confidentially in line with relevant health legislation. All questions marked with a red asterisk must be completed to enable us to assist you.
Please start providing the information now by clicking on the Continue button below.
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| * How did you find out about OnlineCounselling.co.za? |
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| * What is your date of birth? |
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| * Name of emergency contact person: | | |
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| * Telephone number of emergency contact person: | | |
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| * Please provide a brief description of the problem about which you are seeking counselling. Please be as specific as possible about the current problem you are experiencing. | | |
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| Current and previous psychological problems |
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| * When did your problem first start? |
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| * Have you sought help for this problem previously? |
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| When you previously sought help for this problem, who did you consult? |
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| * Are you currently receiving treatment for a mental or emotional condition? |
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| What treatment are you receiving for your mental or emotional condition? |
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| * Have you ever experienced a different psychological or psychiatric problem? |
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| When did you last experience this problem? |
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| If you know it, what was the diagnosis you received for this problem? | | |
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| If you received treatment for this problem, what was the treatment? |
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| * How would you describe your general mood? Please check all that apply. |
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| * Is this a change from your normal mood? |
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| For how long have you been experiencing this mood? |
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| Do you believe you experience mood swings? |
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| If yes, can you describe these mood swings? | | |
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| * How would you describe the quality of your sleep at the moment? |
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| * How would you describe your appetite at the moment? |
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| * Have you lost or gained more than 4kg in the past two months without making any effort to do so? |
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| * How would you describe your energy levels at the moment? |
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| * Do you ever have thoughts that life is not worth living or that you want to take your own life? |
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| Are you currently thinking about taking your life? |
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| For how long have you had suicidal thoughts? |
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| How frequently have you had suicidal thoughts? |
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| Please rate the intensity of your thoughts on the scale below, where 1 indicates very mild suicidal thoughts and 10 represents overwhelming thoughts about suicide.
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| | Mild suicidality | Overwhelming suicidality |
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| Have you considered how you might kill yourself (eg. taking an overdose of pills, hanging yourself, using a gun)? | | |
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| If you have thought of a way of killing yourself, do you currently have access to this method? |
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| Have you taken any active steps to get your affairs in order (eg. updating your will, writing a suicide note)? |
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| When you have suicidal thoughts, what helps you to feel better? | | |
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| What stops you from killing yourself? | | |
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| * Have you attempted to kill yourself in the past? |
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| When did you last attempt suicide? |
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| What method did you use when you last attempted suicide? | | |
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| At the time, did you seriously believe you would die from these self-inflicted injuries? |
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| When you previously attempted suicide, did you plan your suicide carefully prior to taking action? |
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| Did you attempt to notify someone when you attempted suicide? |
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| When you realised that you had not died from your injuries, did you feel disappointed? |
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| Do you still have hope that you might experience happiness in the future? |
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| Have you recently suffered the loss of a significant person in your life (e.g. death of a friend or family member, divorce or separation)? |
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| Have you recently suffered any other significant loss (e.g. the loss of a job, a significant financial loss) |
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| Have you recently felt out of control? |
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| Do you have a friend(s) or family member(s) to whom you can turn for help when you are feeling upset? |
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| What reasons do you currently have for living? | | |
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| How do you believe others will react if you were to attempt suicide? | | |
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| * Do you ever see or hear things that other people cannot see or hear? |
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| What can see or hear that ordinary people cannot see or hear? | | |
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| * Do you ever feel that other people want to harm you? |
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| Who do you think wants to harm you and why? | | |
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| * Do you have special powers that ordinary people do not have? |
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| Can you describe these special powers that you have but other people don't have? | | |
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| * How many units of alcohol do you drink in a week, on average (a unit is equivalent to one beer, a glass of wine or one tot measure of spirits)? | | |
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| * Do you use any other substances (eg. dagga, cocaine, heroine, crack, mandrax, medication not prescribed by your doctor) |
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| How frequently do you use these other substances? |
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| Are you concerned about your substance use and the impact it is having on your work or relationships? |
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| Have you ever had any legal difficulties as a result of your substance use? |
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| How would you prefer to conduct your counseling online? |
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