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What we do
Make an enquiry
• 'Remind client of confidentiality/disclosure boundaries' before Client Name
Date of completion
Form completed by:
Client ID (initials DOB eg, iiddmmyy)
Client's current health and wellbeing status
On a scale of 1 - 20, with 1 being 'Extremely Poor' and 20 being 'Excellent', how would you describe your current health and wellbeing in general?
Please use this field to describe any significant aspects of the above
Describe your health and wellbeing in general (How has the current COVID-19 Situation affected this?)
Please use this field to expand on how any of the above issues are affecting your day to day life
Please use this field to describe any of the above
Do you have any long term physical and/or mental health concerns/conditions/complaints? (Please record in detail any safeguarding or significant risk factors)
If you responded Yes to the above question, please provide us with all the related significant information (diagnosis, medications, year of diagnosis,etc. Current impact on your lifestyle, health and wellbeing) and how this has changed/ been affected by the COVID-19 situation:
Psychological History *(WARN CLIENT OF SENSITIVE NATURE BEFORE ASKING)...Any significant experiences or difficulties, in the past or present that could be described as trauma in it's broadest sense. *If yes; acquire as much detail as possible without causing distress.
Family Constellation and Significant History
How often do you drink alcohol during the week?
I don't drink at all
1-2 days weekly
3-5 days weekly
5-7 days weekly
What type of alcohol do you drink and on average how much per day
How has your alcohol consumption changed since lockdown
My alcohol intake has decreased
My alcohol intake has remained the same
My slcohol consumption has increased slightly
My alcohol consumption has increased significantly
Would you like support to reduce or stop your alcohol use
Yes I'd like to reduce my alcohol intake
Yes, I'd like to stop drinking completely
Do you take any illicit drugs?
Yes but infrequently (less than once per week)
Yes, often (more than two days per week)
Please describe your current drug use including regularity, which substances you are using and how much on average you take when using
Has your drug use changed since lockdown?
Yes, I'm using less than usual
Yes, I'm using more than usual
Would you like support to reduce or stop your drug use?
Yes I would like to reduce my drug use
Yes, I would like to completely stop using illicit substances
Have you had any periods of treatment or complete abstinence from alcohol or drugs
Yes short periods of abstinence (less than one month)
Yes, long periods of abstinence (6 months+)
Do you currently take any medication to help you with your health and wellbeing?
If you are currently taking medication to help you with your health and wellbeing. Please use this space to describe what medication you are currently taking, who prescribed it, reason for use, daily dosage and how long you have been taking the medication
*please note if there have been any changes to prescribed medication as a result of COVID-19 and lockdown restriction
Have you ever received, or are you currently receiving any therapeutic support of any kind?
When was your last session?
For how long were you engaging?
Are you still receiving sessions
How do you feel about the support you have been or currently are receiving?
Do you feel some online sessions could improve your health and wellbeing?
Contextualise client's answer to the above question and offer possible options based on client's answers
Do you have any specific requests to help us determine how we can best support you in your wellbeing?
When would be the most convenient time for you to attend 1:1 sessions?
Referrals to be made and estimated timescale
Click or drag a file to this area to upload.
Please contact us at your earliest convenience if you would like to follow up on any of the above, or simply discuss the feedback you have received by contacting us at:
Book your AzuraMOT