Think CBT Pre-Assessment form
Please complete all sections of this online pre-assessment form. Please enter your initials and a confidential email address. Check that your email address has been entered correctly before submitting this form. This information will be used by your therapist to undertake the initial assessment and will help improve the accuracy and speed of the assessment process. Please Note: Whilst every effort is made to ensure that our system is securely encrypted, email is not a completely secure means of communication. Think CBT does not accept liability for loss or theft of personal data where any individual chooses to transmit or receive information via email.
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1. What are the problems / symptoms you want to work on?
2. What situations or events trigger the problem?
3. How frequently do you experience the problem?





4. How distressing / intense are the symptoms?





5. How does this affect your work / social / personal life?
6. When you experience the problem, what negative thoughts do you have about yourself, other people or the situation?
7. When you experience the problem, how do you feel emotionally; what feelings do you have E.g. anxious, depressed, angry .
8. When you experience the problem, how do you feel physically; what sensations or physical feelings do you notice in your body?
9. When you experience the problem, what do you do or avoid doing?
10. What tends to make the problem worse?
11. What tends to make the problem better?
12. What do you believe are the causes of the problem; what made you vulnerable to the problem in the first instance?
13. Do you ever experience thoughts of harming yourself or ending your life?





14. Please provide details of any current/recent medication.
15. Please provide details of any substance use.
16. Please provide details of any current / recent therapy or counselling undertaken for this or any other problem.
17. Please provide details of any other current or past psychological / medical problems that you have experienced.
18. Please provide your GPs name and practice address.
19. Please provide a preferred telephone number and email address that we can contact you on.
20. Please provide your date of birth.