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Forms

Forms

Please provide your information to the best of your knowledge below, before
meeting with your psychologist.

Consultation Form

The therapy and counseling work we do is unique to you, just as it is to each one of our clients. Before we get started we need to collect some general information from you. Please complete the information that applies to you only and bring it to the first visit. It may seem long, but most of the questions require only a check, so it will go quickly.

General Information

Name*
Date of Birth*
Current Occupation*
Mobile Number*
Highest Education Level or degree obtained *
Current Therapist/Counselor*
Therapist's Phone*
Have you ever served in the military?
Height*
Weight*

Relationship History and Current Family

Are you currently:
How long
If not married, are you currently in a relationship?
Are you sexually active?
How would you identify your sexual orientation?
What is your spouse or significant other's occupation?
Describe your relationship with your spouse or significant other:
Have you had any prior marriages?
If so, how many?
How long?
Do you have children?
If yes, list ages and gender:
What are the problem(s) for which you are seeking help?

Background History

Family Background and Childhood History

Were you adopted?
Where did you grow up
List your siblings and their ages:

Trauma History

Do you have a history of being abused emotionally, sexually, physically or by neglect?
Please describe when, where and by whom:

Family Psychiatric History

Has anyone in your family been diagnosed with or treated for:
Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcohol abuse
Violence
Other substance abuse
If yes, who had each problem?
Has any family member been treated with a psychiatric medication?
If yes, who was treated, what medications did they take, and how effective was the treatment?

Tobacco History

Have you ever smoked cigarettes?
Currently?
How many packs per day on average?
How many years?
In the past?
How many years did you smoke?
When did you quit?
Pipe, cigars, or chewing tobacco: Currently?
In the past?
What kind?
How often per day on average?
How many years?

Alcohol History

Have you ever consumed Alcohol?
Currently?
How many glasses per day on average?
How many years?
In the past?
How many years did you drink?
When did you quit?
List everyone who currently lives with you:
For Female only: Date of last menstrual period:
Are you currently pregnant or do you think you might be pregnant?
Are you planning to get pregnant in the near future?
Birth control method:
How many times have you been pregnant?
How many live births?
For Male only: Are you experiencing Erectile Dysfunction?
Would you like to speak to a male doctor at Kerala Ayurveda Panchakarma Centre?

Mental Health Assessment

Name*
Date of Birth
Current Occupation
Mobile Number
Email
Current Symptoms Checklist: (check for any symptoms present)
Any Current Allergies
Current over-the-counter medications or supplements
Current medical problems
Any Current Issues I should know about not mentioned above

Past Psychiatric History

Outpatient treatment (If yes, Please describe when, by whom, and nature of treatment.)
Reason
Dates Treated
ByWhom
Psychiatric Hospitalization (If yes, describe for what reason, when and where.)
Reason
Date Hospitalized
Where
Past Psychiatric Medications: (If yes, Please list the dates, dosage, and how helpful they were (if you can't remember all the details, just write in what you do remember). )
Name of medication
Dates
Dosage
Response/Side-Effects
Past Counseling (If yes, Please list reason, date, was it helpful, and last visit )
Reason
Date
Effectiveness
Last Visit

Background History

Family Background and Childhood History

Were you adopted?
Where did you grow up
List your siblings and their ages:

Trauma History

Do you have a history of being abused emotionally, sexually, physically or by neglect?
Please describe when, where and by whom:

Family Psychiatric History

Has anyone in your family been diagnosed with or treated for:
Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcohol abuse
Violence
Other substance abuse
If yes, who had each problem?
Has any family member been treated with a psychiatric medication?
If yes, who was treated, what medications did they take, and how effective was the treatment?

Consent to Treatment

Mental health is the connection between mind, body and soul. At KKK Counseling we have partnered with the world's oldest holistic healing systems “Ayurveda” with the modern science of “Psychology" to help our clients. Our counselor is specialized in suicide prevention and childhood trauma. Our counseling services are for teens, adults, couples and LGBT community. Services are conducted online and in-person at our office. Services include but not limited to stress, anxiety, OCD, emotional support, postpartum depression, sexual abuse, academic problems, depression, sleeplessness, exam fear, and many other mental health issues. You don’t believe in modern science it’s absolutely okay. Our Ayurvedic doctor has many other holistic treatments such as shiro dhara and herbal medicines that will help with memory, anxiety, sexual problems, sleep disorder and other issues. We believe in your well-being and understand the importance of mental health throughout the live. All our sessions are confidential and your identity is always protected. By providing the information below you are agreeing to enter a truth-worthy relationship with KKK Counseling. You also understand that you have the right to stop therapeutic sessions if it is not beneficial to you. Therapist reserves the right to stop the therapeutic relationship if it is determined that it is not in the client(s) best interest.

Name
Date of Birth

Confidentially

You are our client and have confidentially rights. Confidentiality does not apply under certain situation: We are obligated by law to report any suspicion of child abuse. This includes physical or sexual abuse. Also, we have a duty to protect if we suspect anyone is in danger of killing themselves or has made threats to hurt someone else. Except in these rare situations, your child has the right to keep particular topics confidential from even his/her guardian. Please respect this confidentiality. Again, if there is any concern of harm, suicide or other dangerous behavior, we will inform you. If I require or think it is in your best interest to communicate with an outside source, I will request a release of information. To assure good therapeutic care, frequent appointments are required. Unless arranged otherwise, clients that have not been seen in 3 months will be considered inactive. A new evaluation will be required for any inactive client to be seen.

Name
Date of Birth

Online Counseling Form

First Name*
Last Name*
Email*
Mobile Number*
Country*
Sex
Preferred method of contact*
Please tell us your concern*

Tell US

First Name*
Email*
Mobile Number*
Subject*
Message